Facility Evaluation Report

On 7/9/2025, Licensing Program Analyst (LPA) K. J. Leffall arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and met with Administrator(A1) Mandy Rancour.

LPA conducted facility tour with A1. LPAs observed required posting. All pathways, entrances and exits were clear from obstruction. LPA toured locked office storage rooms, and laundry rooms. LPA observed facility common areas which were furnished with sufficient seating. The tour continued to the facility dining room and facility kitchen. The kitchen was observed clean, in good repair with necessary items and appliances. LPA did not observe 7-day supply of nonperishable food. 2-Day perishable foods observed. LPA toured several resident rooms which were observed to be furnished with required furniture and adequate lighting. Fire extinguishers observed throughout the facility with service date of 2/10/25. Bathrooms were properly equipped with non-slip mats and grab bars. Carbon monoxide detector tested and operational in two hallways. Memory care toured with dining area/ Kitchen; several rooms toured. Residents observed with several caregivers in commons playing a trivia game on television. LPA toured an enclosed patio area with sufficient seating and shade for recreational purposes. LPA observed delayed egress doors. Facility observed with a signal system. LPA toured main outside Patio from dinning room which was observed with seating and shade. Samples of staff and resident files reviewed to have the required documents.

Fire drill conducted on 6/6/2025. Annual Fire Alarm inspection & Testing completed on 6/30/2025. LPA reviewed resident's medication, MARS, and Centrally Stored Medication and Destruction Record (CSMDR)