Routine inspection·August 7, 2025

Licensing Program Analyst (LPA) Vaid conducted an unannounced annual inspection visit. LPA met with Administrator Crystene Char and the purpose of today's visit was discussed. The facility has a capacity of 90 residents and licensed to serve elderly residents age 60 and above. The facility is approved for fifty-six (56) non-ambulatory residents. The facility has eight (8) hospice waiver on file, eight (8) residents are on hospice, and four (4) residents with dementia. Administrator certificate is current and expiring on 12/20/2026. The annual inspection consisted of applying CARE tools; conducting physical plant; reviewing food supply, staff and residents’ files, and medication; and interviewing of staff/residents. The facility is a two-story building with 63 resident rooms. The facility consists of seven (7) office rooms, reception area, med room, library, activity room, dining room, kitchen, two (2) laundry rooms, two (2) housekeeping storage rooms, staff lounge, and courtyard. Four (4) public restrooms are available which are clean and operational. 1.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. [ CONTINUED ON 809C .....] 2.Operational Requirements: The fire clearance is approved has a capacity of 90 residents and licensed to serve elderly residents age 60 and above. The facility is approved for fifty-six (56) non-ambulatory residents. The facility has eight (8) hospice waiver on file, eight (8) residents are on hospice, and four (4) residents with dementia. Staff are adhering to operational requirements. 3.Physical Plant & Environment Safety: LPAs toured facility grounds. Smoke alarms and carbon monoxide detectors were observed. Both, smoke alarms and carbon monoxide detectors are operable. Fire extinguishers are located throughout the premises (service date of 12/17/2024) Water temperature measured in eight (8) residents’ bathrooms is within 105-120 degree F. Bathrooms had non-skid surfaces and grab bars. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. 4.Staffing: Facility has reasonable staffing; staff was observed assisting residents with their activities. 5.Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for S-#1 through Staff #6. Staff have their Health and TB Screening on file. Association and clearance. 6.Resident Rights-Information: Resident rights are included in Resident files. The let-us-no and ombudsman posters were observed to be posted in the hallway near the reception desk. 7.Planned Activities: Activity schedule/calendar is posted inside the activity room. There is an activity coordinator and activity assistant for this facility on weekly basis. 8.Food Service: Dining area has adequate seating. Plates, cups and utensils are kept cleaned and stored properly. Kitchen is kept clean and free from rodents and other vermin. There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator and freezer. Pesticides and cleaning supplies are kept away from the food preparation areas. [ CONTINUED ON 809C.....] 9.Incidental M&D: The medications are centrally stored in the medication room and in bubble packs and/or original containers. Medications are administered as prescribed by the Physician and marked in the Medicine Administered Record(MARs). 10.Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 through Resident #7. 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, Functional Capabilities, ALW assessment and Resident Rights were observed. 11.Disaster Preparedness: The facility has the Emergency Disaster Plan in place. The emergency disaster drills include fire, elopement, stairwell evacuation, conducted every quarter. Last emergency drill was on 6/26/2025. Disaster training is conducted by the corporate office every quarter. 12.Residents with SHN: Facility does not use manual restraints at this facility. No deficiencies were noted on today's visit. An exit interview was conducted with Administrator Crystene Char and copy of LIC 809s were provided.