Facility Evaluation Report

On 04/22/2025 at 8:30am, Licensing Program Analyst (LPA) Pang Lee and Shakaricka Hughes arrived at the facility to conduct an unannounced annual inspection. LPA Lee and Hughes met with Kathleen Gilbey explained the purpose of the visit. The facility designated administrator was present in the facility. The current census is 146 and facility staff is 112

LPA's inspected the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA's also toured both the assistant living and memory care. LPA's observed activity rooms, wellness cove, private dining, massage room, and media ballroom. LPA's observed sufficient lighting throughout the facility. LPA's observed the facility to be clean and in good repair. LPA observed residents’ rooms and they are equipped with the required furniture. LPA's observed resident room 109 had a very strong urine odor. It was learned R1 moved to the facility of 2/1/2025 and it was learned that resident has a change in condition. Based on record review, resident has proper documentation in place. During today's visit maintenance shampooed resident's carpet. Resident will relocate to another room temporarily. There are no bodies of water present.

LPA's toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 109.1 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety.