Facility Evaluation Report

On 10/02/2025, Licensing Program Analyst (LPA) Renee Campbelll arrived unannounced to conduct an annual inspection with Stephenie Doub, Regional Manager. Krystal Calderon, Administrative Assistant assisted with the visit. LPA Campbell observed residents eating breakfast. The contact information for the Long-Term Care Ombudsman was displayed in the entrance for residents and visitors. There was also a See Something Say Something poster available to call in complaints. Throughout the day, LPA Campbell overheard residents using the signal system to call for a caregiver. Later during the visit, LPA Campbell observed two residents working on a puzzle together and a religious service was done in the common area with a priest and residents as parishioners. Upstairs, residents were observed eating lunch in the dining room. Staff were observed serving the meals and assisting where needed.

The community is licensed to serve residents age 60 and over who are non-ambulatory of which 16 of them may be bedridden. Only the first floor is approved for bedridden residents and the community has a waiver granted for 16 hospice residents. A tour was conducted with Dawn Pero, Care Coordinator in the Med room, resident rooms, kitchen and common areas.

LPA Campbell conducted a medication audit using randomly selected residents and found that the residents medication matched their name, rx, number, name of medication and the dosage prescribed. The first aid kit was inspected and included tweezers, scissors, thermometer and first aid manual along with bandages.