Facility Evaluation Report

At 9:00am, on 12/16/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Administrator Carl Meyer, announced who he was and the reason for the visit.

This is a three story facility with ninety-seven resident rooms, of which twenty-four are in Compass Rose, the memory care unit on the south end of the second floor. The main entrance is located on the second floor. LPA noted a large lobby space when entering the front door with a reception desk, administrative offices, a television displaying activities, announcements, and menu items, and multiple areas for residents and guests to sit and visit. The facility has smoke detectors in each bedroom room and throughout the facility that were tested by Alpha Fire & Security Alarm on 11/20/2025 and a sprinkler system also tested on 11/20/2025.

There are two rooms for resident medication storage, one in the memory care unit Compass Rose and the other located in a room on the second floor of the assisted living portion of the facility. At approximately 10:00am LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records (CSMRs), finding nineteen (19) medications not documented on resident CSMRs. Staff could not provide documentation of these nineteen medications centrally stored.

LPA was not able to complete the annual inspection and may return at a later time to finish.

Exit interview conducted, deficiency cited on LIC809-D, reports signed, reports and appeal rights provided to Administrator Carl Meyer.