Routine inspection (multi-day)·July 13, 2024

Licensing Program Analyst (LPA) Kimberly Ramirez conducted subsequent annual inspection on 7/13/2024. LPA met with Lynn Palin (Director of Social Work) and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Operational Requirements: This facility is licensed to serve fourteen (14) ambulatory residents and five hundred sixty (560) non-ambulatory residents over the age of 60. This facility may retain no more than fifteen (15) hospice residents. There are six (6) residents under hospice care. This facility provides care to assisted living residents in 4 different wings of the facility. Pinecrest census – four (4), Cedar Court census – eleven (11), Maple Court/Birch Court census – thirty-four (34), and twenty-two (22) in Southwoods Lodge Memory Care. Southwoods Lodge Memory Care is approved for delay egress. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for six (6) out of the nine (9) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for nine (9) out of the nine (9) personnel records reviewed. Staffing: Administrator Certificate for Keith Kasin (70005649740) expires 08/10/2024 and is in the process of being renewed. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. The facility provides incidental medical services. See 809-C for continuation. Resident Records/Incident Reports: LPA Ramirez reviewed Resident files for nine (9) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. No deficiencies were observed during this inspection. Exit interview was conducted. A copy of this report was provided.