Routine inspection·December 9, 2025

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required - 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Priscilla Gayton, Administrator, the purpose of the visit was explained. The following (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan. Operational Requirements: A current Plan of Operation was reviewed. The facility serves residents 60 years and older, and a Hospice Waiver for thirty (30) resident is approved. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 06/01/2026. A surety bond is not applicable. Facility does not handle resident's money. (continued on 809C) (continued from 809) Physical Plant/Environment Safety: The facility is a two-story building, approved to care for 343 non-ambulatory elderly residents, ages 60 and over. The facility has a memory care unit for dementia residents and has a hospice waiver approved for (30). LPA inspected random resident bedrooms and observed them to have the required furniture, bedding, linens,, closet space, and additional storage space. Each resident bedroom is equipped with a bathroom that consists of a shower, toilet, and wash basin One resident had two light bulbs out and they were replaced during visit. The showers accommodate non-ambulatory residents and have the required grab-bars and non-skid mats. Several fire extinguishers were observed throughout the facility. Water temperature measure between 106.0 – 113.7 which is within range of 105.0 -120.0 degrees F: in random rooms that were inspected. All toxins such as cleaning solutions and detergent soap are also locked in the storage room. The grounds of the facility are well landscaped, and facility is clean and free of odors. Fire department inspected the sprinkler system on 02/26/2025 and passed. Smoke detectors were tested and operational in random rooms checked. A shaded area with chairs is provided. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises. Staffing: There appears to be always sufficient staffing in the facility. With night staff that is trained and able to assist in care and supervision of the residents in case of an emergency. Personnel Records/Staff Training: Staff have criminal record clearance, current First-Aid training, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 6 staff files with no issues observed. Administrator Priscilla Gayton certificate expires on 03/04/2026 (continued on 809C) (continued from 809C) Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. The facility does have a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and storage areas consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Incident Medical and Dental: Six (6) centrally stored resident medications were reviewed. All medications are administered as order by the physician. Medical and dental transportation is provided by family, transportation services, or staff. Resident records/incident reports Resident files included appraisals, TB clearance, Functional Capability Assessment, and emergency information. RCFE complaint poster and Personal rights were observed posted in the facility hallway. One resident did not have ambulation status on LIC610 Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. No deficiencies observed during the visit. Technical Violations issued. Exit interview was conducted with Anne Graves, LVN Supervisor. A copy of the report and appeal rights were issued.