Routine inspection·November 14, 2025

On November 14, 2025, at 10:15 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Susan McClure and explained the purpose of today's visit. Administrator holds current certificate and expires in January 2026. The facility is licensed for 144 non-ambulatory residents. There are currently 84 residents who reside at this facility. The facility has an approved hospice waiver for ten. The facility's last fire alarm system inspection was completed on April 11, 2025. The last fire testing and and maintenance inspection was on May 20, 2025. Last fire inspection report indicates fire sprinklers are not in good repair and water gong is in operable. The last fire drill documentation states March 10, 2025. The facility shall conduct a drill at least quarterly for each shift. LPA Martinez reviewed the inspection control plan and disaster preparedness plan. LPA Martinez reviewed food service consultation report. The last food service consultation was in December of 2019, and LPA Martinez was informed by S1 there is not a nutritionist, dietitian, or home economist available at the facility. Continued... LPA Martinez reviewed two medication administration records (MARs). Resident 1 (R1) was not maintained. R1's MAR was not signed on November 5th and 8th. R1's vitamin B-12 MAR entry does not reflect medication order. MAR entry for B-12 states 500 MG; the Medication Bottle states 1,000 MG; The medication order states 1,000 MG. R1's Donepezil HCL bottle label order was altered with a black marker. The Donepezil bottle states 10 MG and medication order states 5 MG. Additionally, there is no Donepezil split order documentation. R1's Ferrous sulfate 325 MG Tablet MAR entry does not reflect the medication bottle order. LPA Martinez will return at a later date and time to complete 2025 annual inspection. The following deficiencies can be found on the D-Page: Fire Safety 87203, 1569.695 (c); Emergency Plans; and Incidental and Medical 87465(a)(6); Incidental and Medical 87465(h)(4). An exit interview was conducted and a copy of this 809 report, 809-D page, and appeals rights were provided to the facility.