Routine inspection·August 1, 2025

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a unannounced required annual inspection on 08/01/2025 . LPA Ramirez identified herself and met with CEO-Matthew Neeley 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: 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 eight (8) residents under hospice care at this time. This facility provides care to assisted living residents in 4 different wings of the facility. Pinecrest census – seventeen (17), Cedar Court census – ten (10), Maple Court/Birch Court census – forty-nine (49), and twenty-four (24) in Southwood Lodge Memory Care. The Southwood Lodge Memory Care is approved for delay egress. The total census for this facility is two hundred seventy seventy (277) as of 08/1/2025. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: See 809-C for continuation. Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained the required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. Facility maintains a monthly waterlog to record water temperature throughout the facility. LPA Ramirez observed postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed evacuation chairs in stairways. Food Service: LPA Ramirez observed sufficient supply of non-perishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with a maximum temperature of 40-degree F. (4 degree C). LPA Ramirez observed facility weekly and daily menu. LPA Ramirez observed kitchen staff performing a deep cleaning of the kitchen area. LPA Ramirez observed several dining room servers disinfecting tables and counters while wearing gloves and hair nets. Planned Activities: LPA Ramirez observed several residents participating in a staff-led seated exercise. LPA Ramirez observed a calendar for August of 2025 with various activities and outings for residents. LPA Ramirez observed sufficient outdoor space in both assisted living section and in memory care. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed internet access and a facility land line. SEE 809-C for continued report. Residents with Special Needs: Facility pool was observed to be inaccessible to residents with physical and mental disabilities. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps, or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. Due to time constraints, LPA Ramirez will return later to complete annual inspection. No deficiencies were cited at this time. Exit interview was conducted with Matthew Neeley. A copy of this report was provided.