Routine inspection·June 11, 2026

At approximately 8:45 a.m. on 06/11/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator and disclosed the reason for the visit. A file review was conducted prior to the visit. The facility was last visited on 06/02/26 for a complaint visit. It is a three (03) story building with a capacity of 176 residents. LPA observed offices, bedrooms, shared and private bathrooms, kitchen and dining areas, garage, common areas, activity rooms, garage, and a courtyard. It has an approved fire clearance for 176 nonambulatory residents, of which fifty (50) may be bedridden. Approved hospice waivers for thirty (30). At 8:50 a.m., LPA inspected the facility vehicle. All systems were operational. LPA conducted a file review at 9:30 a.m. The Emergency Disaster Plan was last reviewed on 05/10/26. Liability Insurance was updated on 01/01/26. The Infection Control Plan was last updated on 12/05/25. The Dietitian/Nutritionist consultation was performed on 03/06/26. REG4 fire testing was completed on 04/03/26. All systems passed inspection. LPA reviewed at least ten (10) percent of staff and resident files. All files were complete, current, and available for audit. LPA observed new carpets and fresh paint on hallway walls on the first floor. Interview with the maintenance director at 9:05 a.m. revealed the first floor was renovated in February 2026. Between 12:00 p.m. and 2:00 p.m. today, LPA and the administrator toured the facility. Cameras were observed near the main entrance. The designated smoking area at the front contained artificial shrubs and umbrellas for shade. Postings were observed inside for COVID precautions, emergency contacts, Ombudsman contacts, confidential complaint contacts, facility license, facility sketch, emergency disaster plan, administrator certificate, personal rights, rights of resident councils, normal and alternate menus, and daily and monthly activity calendars. Walls, floors, windows, screens, and blinds were clean, free from stains, and in good repair. An activity room near the reception desk had a television, exercise equipment, a piano, a sound system, and sufficient activity space. Activities were observed and conducted at 9:00 a.m. today. The reception area had seating, board games, an administrator office, a business office, and mailboxes. Personnel files were stored and locked in the business office. At approximately 12:15 p.m., fully-charged fire extinguishers were observed near the main entrance, the kitchen, and hallways of all floors. They were last inspected on 04/10/26 with tags attached. At 12:25 p.m. the room temperature was measured to be 78 degrees Fahrenheit. Rooms #314 and #214 were inspected. All rooms contained functional smoke alarms, appropriately furnished bedding, chairs, nightstands, storage, lighting, and bathrooms with paper towels, liquid soap, grab bars near the toilets and showers, and non-skid mats or strips in the shower. All rooms were clean and in good repair. Water temperatures in bathrooms were tested at 12:40 p.m. and 1:10 p.m. and measured to be between 110.1 and 105.4 degrees Fahrenheit, respectively. The second floor contained a medication room, activity room, a locked salon, and resident rooms. The medication room contained a fully-stocked first aid kit, inaccessible medications, medicine refrigerators, and locked medication carts with secondary locks for controlled substances. The activity room contained reading material, games, puzzles, and exercise equipment. Fire doors were observed in hallways. Fire sprinklers were observed throughout the building. Water, coffee, and snacks were available on the first and second floors. The third floor contained resident rooms. The door to the roof access was locked. The rear elevator accessed the third floor and was operational with a permit approved on 06/01/26. Two (02) out of two (02) stairwells had emergency evacuation chairs at the tops of the stairwells. No hazards were observed in stairwells or emergency exit paths. All emergency exits were unlocked. All electrical rooms, maintenance rooms, and roof access doors were locked. The garage was free of hazards. The courtyard contained plants and trees and two (02) shaded seating areas. LPA observed three (03) dining areas near the kitchen. The kitchen contained an adequate supply of perishable, non-perishable, and emergency foods. The dishwashing area was free of debris and vermin. Appliances were in good condition. Cleaning solutions and sharps were inaccessible. At approximately 1:40 p.m. today, the walk-in freezer and refrigerator temperatures were measured to be -20 and 3 degrees Fahrenheit. Temperature and maintenance logs were observed near appliances. Two (02) washing machines and two (02) dryers were located in the laundry room. Both were in working order. Detergents were stored and locked. At 2:00 p.m. the carbon monoxide detector in the lobby was tested to be operational. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health or safety hazards were observed. Exit interview conducted. Copy of report provided.