Facility Evaluation Report

On 09/25/25 Licensing Program Analyst (LPA) Javina George made an unannounced 1 year required visit. LPA met with Nathan Boese, Assistant Executive Director and informed of the purpose of the visit. The facility is licensed to serve. The facility has an approved hospice waiver for (16) residents with (9) currently receiving services. There are (61) residents receiving home health services and (3) residents that are self administering oxygen. A file review was conducted prior to making today's visit. The facility annual fees have been paid, and the governing body was observed to be in good standing. Below are the observations made during today's visit.

The facility was observed to be clean and the passageways being free of any obstructions. The facility was observed to have the required postings. The fire extinguishers were fully charged and last serviced on 03/12/25. The emergency disaster drills are being conducted on a monthly basis, with the last drill being conducted on 09/19/25. The smoke and carbon monoxide detectors were observed to be operable and were being serviced during LPAs visit. The pull cords were randomly tested and found to be operable. The pool was observed to be secured. There are no known guns or ammunition on the premises. The hot water tested and found to be within regulatory limits. The medications and medication carts were locked inside the medication room. The facility is using and electronic MAR system. The sharps and chemicals were observed to be locked and inaccessible to residents in care.

A file review of both staff and resident files were conducted. All staff interviewed and files reviewed were observed to have obtained criminal record clearance and to be associated to the facility. The Resident Medical Assistant staff were observed to possess valid CPR certification. The administrator Monique Moreira was observed to have valid certification that expires on 02/19/26.