Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management inspection and met with Annet Nakiyuka, Administrator (Admin).

LPA and Admin conducted a tour of Memory Care (MC) units, part of facility's "Phase 3C" expansion. On 2/25/2025, fire clearance was granted for increased capacity of 400 non-ambulatory residents, an increase from 376 residents to now include Memory Care. Memory Care units are located on Level 1 of the Main Building in sections H and I.

Facility has a MC lobby waiting area in which the entrance door to the MC unit is located. Currently, the door does not latch and is not working as a delayed egress door. LPA and Admin spoke with Darcy Wallace, Director of Facilities (DOF). He explained that the door is being repaired and will have a magnetic function added to it such that it will latch properly and function as a delayed egress door from both sides. He also indicated that they identified a faulty wire related to the functionality of the door that is also being repaired/replaced.

Kitchen for MC unit includes access to refrigerator, sink, and range/oven. LPA noticed locking mechanism on the refrigerator. Admin explained that it will be removed and was only there temporarily. LPA and Admin tried to get a hot water temperature reading from the kitchen sink but could not get any hot water to dispense. Bathroom sinks in the kitchen bathrooms also do not dispense hot water and only dispense water when the motion sensor is activated and a hand (or solid object) is maintained in front of the sensor. LPA and Admin discussed this functionality to potentially be problematic for MC residents to use. Admin will look for an alternative option and report back to LPA. Range/stove top of oven in MC kitchen has a locking feature. A key must be inserted into the lock on the wall to in order for the knobs on the oven to function properly and turn on the heating elements. LPA and Admin discussed adding a barrier of some kind that will prevent MC