Routine inspection·November 7, 2024

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Meagan Swan and explained the reason for the visit. Facility is licensed to serve 66 residents over 59 years old of which 26 may be non-ambulatory and 40 may be bedridden. Facility is approved to retain/accept fifteen (15) hospice residents. Facility is a campus area with separate cottage buildings which are identify as the Ranch House (Dementia unit), the Hearth and Stewart Cottage (Assisted Living), a kitchen and dining area in the Commons building. LPA Flores conducted a tour with Meagan Swan and observed the following: The Commons - is composed of a library area, mail room, offices, dining room, an outdoor dining area and commercial kitchen. The building is in good repair and each area is properly furnished. The kitchen was observed clean with refrigerators, freezers, and walking pantry which store at least 2 days of perishables and 7 days of non-perishables. The Hearth - is composed of different studio resident rooms with private bathrooms, an activity room, and a medication room. Activity room was observed furnished and fireplace was covered. Three rooms were observed with sufficient lighting, furniture, and bedding supplies. Bathrooms were observed in good repair, each with skid mats, and grab bars, and water temperature was tested between 109.2 - 114.5 degrees F. Stewart - is composed of resident rooms some with half bathrooms and some with full bathrooms. A dining/activity room, two family rooms, a shower room, a medication room, and a few offices. Three rooms were observed with sufficient lighting, the required furniture and bedding supplies. Bathrooms in each room were observed in working condition with grab bars. Rooms #12 and #18 did not have skid mats/strips. Water temperature was tested between 80.9 - 105.8 degrees F. The Ranch (dementia unit) - is composed of resident bedrooms with private bathrooms, a kitchenette, a living/dining room area, a medication room, and a fenced outdoor patio. (CONTINUED ON LIC 809C) Each exit has a delay egress system. Kitchenette was observed clean, under sink cabinet was observed to store chemicals and was unlocked at the time of the visit. Two rooms were observed with sufficient lighting, furniture, and bedding supplies. Water temperature was tested between 103.0 - 107.6 degrees F. Water temperature in room #12 in Stewart cottage was tested at 80.9 degrees F., which is not within the required 105-120 degrees F. Fire sprinkle system is installed in each building and are in working condition. Fire extinguishers were observed. Residents' beds that were observed with bed rails have a bed rail request on file. Garden walk area outside the Commons has two fish/turtle ponds that are wired across and less than 2 ft in depth. Community's pool has a 5ft fence. At around 1:15pm LPA observed Resident #6(R6) using a merry walker at the facility and no postural support physician's request was noted by a physician. Files and medication was checked for 5 residents. Hospice file was observed for one resident. Five (5) staff files were reviewed. Staff #3(S3) does not have 20 hours of training within the last 12 months. Administrator certificate was observed for Deborah Herbert #6003728740 exp. date: 5/2/25. At least one staff during each shift has a current First Aid/CPR training certificate. Infection Control and Emergency disaster plans were reviewed and have been reviewed/updated within the last 12 months. Exit interview was conducted with Meagan Swan and a copy of this report, LIC 809D, and appeal rights were provided.