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32 | Regarding the allegation: Licensee does not ensure that resident rooms have closets. It is being alleged that resident rooms do not have closets. During LPA's physical tour, LPA observed five (5) rooms to have closets, dressers, televisions, proper lighting. LPA conducted five (5) resident interviews that confirmed they are happy with their room and with the facility. LPA interviewed three (3) staff that confirmed no residents have complained about their room not having proper furnishings. Therefore, based on the interviews and room observations conducted the allegation(s) is UNSUBSTANTIATED at this time.
Regarding the allegation: Licensee has not posted an updated emergency evacuation plan that includes all resident rooms. It is being alleged that the facility’s posted emergency evacuation plan does not include all rooms. During LPA's physical tour, LPA observed an updated Emergency Disaster Plan against the wall of the facility leading to the left hand entrance of the facility dated 01/10/26 along with the facility sketch. LPA also obtained the facility sketch that shows the 30 rooms in the main building of which some are shared, four (4) of which are for bedridden use room 11 and 28 and the eleven (11) ambulatory rooms in the two (2) cottage areas in the back of the facility. LPA interviewed three (3) staff that stated the rooms have remained the same for over ten (10) through fifteen (15) years since they have been working there and there has been no new construction. LPA also interviewed four (4) out of five (5) residents that stated, "there has been no new construction since they have been living at the facility." One (1) out of the five (5) residents stated, "there was construction maybe fifteen (15) years ago but they cannot remember the exact date, which was changed by the former administrator and does not have any proof." Therefore, based on the interviews, room observations and facility sketch conducted the allegation(s) is UNSUBSTANTIATED at this time.
An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.
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