Routine inspection·May 1, 2025

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Executive Director (ED) James Craddock and explained the reason for the visit. James Craddock's Administrator's Certificate expires on November 8, 2026. Facility is licensed for 140 non-ambulatory residents with a hospice waiver for 10. The facility is composed of two buildings connected by a hallway. The main building (building B) is 3 stories and houses the memory care unit on the second floor. The secondary building (building A) is two stories. Building B has an interior outdoor courtyard with a water fountain. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry way of the facility. LPA and ED toured the facility. LPA observed the kitchen and dining room are clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. Emergency food and water are stored in a storage room next to the kitchen. LPA observed the TV/Library room on the first floor. There is a large screen TV, books and magazines and games for residents. LPA and ED toured 9 resident rooms. All 9 resident rooms had the required furnishings. All rooms inspected had clean and operational bathrooms. Hot water measured 105.0 degrees Fahrenheit to 120.2 degrees Fahrenheit in all 9 bathrooms inspected. LPA observed all the fire extinguishers throughout the facility are fully charged. The facility has 4 stairways. LPA observed and emergency evacuation chair at each stairway. The last fire drill was conducted on April 15, 2025. LPA observed medication is kept locked in a cart in the medication room. The first aid kit in the medication room has all the required elements. LPA and the Executive Director toured the second floor memory care. . LPA tested the delayed egress doors in memory care unit. Both delayed egress doors tested operational. LPA observed shaded outdoor seating next to the dining room and in the interior courtyard. No obstacles or hazards observed inside or outside of the facility. During the visit LPA observed residents participating in a trivia activity in the TV/Library room. There is a computer with internet access in the TV/Library room that is dedicated for resident use. LPA interviewed 4 staff and 4 residents. LPA reviewed 6 staff files. All staff are background cleared and associated to the facility. All staff files reviewed had the required training. No discrepancies observed in the staff files. LPA reviewed 9 resident records and medications, no discrepancies were observed. No deficiencies are being cited as a result of this visit. An exit interview was conducted with the Executive Director and a copy of the report provided.