Facility Evaluation Report

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry and met with Tana McMillon, Regional Vice President of Operationsr at 12:30pm and explained the purpose of the visit.

The facility is a two-story building with a capacity of seventy non-ambulatory residents; of which twenty-five may be bedridden. The facility is divided into two communities. The first level is the Birch community and the second level is the Peppertree community. The facility currently has a census of forty-three residents in care.

During today's visit, LPA toured the facility and inspected the physical plant . LPA tested hot water temperatures in five of five resident bathrooms. The hot water temperature measured between 107.9 and 113.0 d egrees Fahrenheit . Resident apartments had the required furnishings and were clean with no hazards observed.

The fire sprinklers, smoke alarms and carbon monoxide detectors are tested annually and were tested on October 17, 2024. The next test is scheduled for November 11-12, 2025. The Director of Plant Operations (DPO) will email LPA with results from the November 11-12, 2025 inspection. There are fourteen fire extinguishers throughout the community and they were charged and were serviced on May 21, 2025. The facility’s last fire drill was conducted on September 7, 2025 and evacuation chairs were observed in stairwells. LPA and DPO tested the delayed egress doors in the Birch neighborhood and egress door released after thirty seconds.