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25 | At approximately 10:00 a.m. on 09/03/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with the administrator and disclosed the reason for the visit.
The facility was last visited on 07/21/26 for a complaint visit. It is a two story building with private apartments, living rooms, shared and private dining rooms, activity rooms, card room, beauty salon, two (02) gyms, four (04) laundry rooms, medication room, business offices, courtyards, and outdoor areas. It has an approved fire clearance for 130 nonambulatory residents. Approved hospice waivers for 7.
LPA reviewed staff and resident files at 10:10 a.m. All files were complete, current, and available for audit. Additionally, LPA reviewed REG4 fire testing which was completed on 07/30/26 with all systems passing, the certificate of liability insurance which is valid until 04/30/26, and a recent dietitian report from 02/04/26.
Around 11:00 a.m., LPA observed residents sitting in the front shaded area. The facility displayed postings for confidential complaint contacts, facility sketch, facility license, emergency disaster plan, rights of resident councils, weekly menu, and activity schedule. The reception area contained a sign-in sheet for visitors and residents and a fully-stocked first aid kit.
In the kitchen, LPA observed an adequate supply of perishable and non-perishable food. Around 11:15 a.m. LPA observed temperature logs for the refrigerator, freezer, and hot water for washing dishes. At 11:25 a.m. LPA measured the refrigerator and freezer temperatures to be 38 degrees Fahrenheit and 0 degrees Fahrenheit, respectively. Hoods were clean and free of debris. Appliances were functional. All surfaces were sanitary. Dietary cards and preferences with resident photos, sanitation logs, and weekly, daily, and alternative menus were posted.
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