Facility Evaluation Report

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 125 non-ambulatory residents. Facility has an approved hospice waiver for 25 residents and the facility currently has 118 residents. Executive Director (ED) Bryan Hadley arrived to assist with the inspection.

LPA along with staff toured the facility at 10:30 AM. LPA toured the physical plant, checked food service, and facility documentation. The facility is a two story building with 114 resident rooms which includes a memory care unit. LPA selected 12 random resident rooms to inspect. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 102.2 degrees F and 109.5 degrees F in all bathrooms checked. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. At 10:45am, LPA observed prescription nasal spray in Resident 1 (R1)'s bathroom. At 10:50am, LPA observed over the counter pain medication in Resident 3 (R3)'s bathroom. At 11am, LPA observed medications in Resident 4 (R4)'s bathroom. At 11:17am, LPA observed neosporin and antiseptic spray in Resident 2 (R2)'s bathroom. Review of their most recent medical assessments on file for those four residents state they are not allowed to store medications in their rooms. Common areas were clean and clear of hazards. Egress exit alarms were operational during today's visit. The facility's four stairwells had an evacuation chair each. LPA toured the kitchen and observed sufficient perishable and non-perishable food supply. Kitchen appliances were operational during today's visit. Fire alarm systems were last serviced on 6/9/2026. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough.