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13 | At approximately 8:30 a.m. on 12/22/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit.
To investigate the allegations above, LPA interviewed staff and residents between 8:40 a.m. and 1:30 p.m. today, toured the facility inside and out at 9:00 a.m., and conducted a record review of pertinent records, including but not limited to a medical assessment, care plan, medication record, and resident roster at 11:15 a.m.
Regarding the allegation ”Staff do not prevent residents from smoking in non-designated areas” it was alleged residents smoked in the central courtyard, garage, and in a room which affected the health of Resident #1 (R1). During the facility tour, LPA observed four (04) residents smoking in the designated area near the street. |