Routine inspection·August 29, 2024

On 08/29/2024 at 11:45 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Director of Residents Services (DRS), Sheila Roberts and explained the purpose of the visit. Executive Director (ED), Tracey Ingleman, arrived approximately 30 minutes later. The facility’s fire clearance was approved for capacity of 175 residents all may be non-ambulatory. Hospice waiver for fourteen (14) residents. Bedridden fire clearance for six (6) on first floor only. Administrator Certificate # 6029374740 Expires 07/07/2025. LPA toured the facility with ED including but not limited to five (5) residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 75 and 74 degrees F. The hot water temperature in a sample of residents’ shared bathroom were measured at 107.1, 109.0, 104.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic chemicals are locked and inaccessible to residents in care. Maintenance on six (6) buses and wheelchair vans updated. LPA reviewed eight (8) residents records. LPA reviewed nine (9) staff records and 9 of 9 have current first aid training and associated to the facility. LIC809-C Continued... LIC809-C Continued... Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/05/2024: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan (with last page dated and signed) Copy of Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.