Routine inspection·March 5, 2025

Licensing Program Analysts (LPA)'s Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA met with Administrator Ashley Candelas. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Administrator. A tour of the facility was conducted with the Administrator. LPA Doucette observed 6 resident apartments. Residents' apartments were toured and inspected and observed to be clean. Hot water temperature was measured from 105.4 to 114.4 F. Residents were observed to be participating in activities in the activity room. Kitchen toured, supply of food observed to have a 2 day supply of perishable. Facility did not have a seven day supply of non perishable. LPA took photos. Medications were stored in a locked Medication cart and in a locked medication room. Cleaning supplies were in a locked storage closet. Facility has a pull station fire alarm and a fire panel and sprinkler system. Fire extinguishers were charged and had service dates of 12/19/24. Resident, medication and staff records were reviewed. R7 did not have a labeled prescription for aspirin from pharmacy. Facility did not have centrally stored logs. S1 verbally stated cycled medications are not logged and all cycled medications start on the 15th of every month. R7's D3, which was said to be a cycled medication did not start until February 19, 2025. Facility did not have hospice care plan identifying the duties of facility staff. S1 did not have all required 20 hour training. Staff did have CPR/First aid training. There was outdoor seating for the residents. See attached 809D. An exit interview was conducted with the Administrator. A copy of this report, plan of correction and appeal rights were provided.