Routine inspection·July 3, 2025

At 8:45 a.m. on 07/03/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the interim Executive Director (ED) and disclosed the reason for the visit. The facility was last visited on 06/06/25 for a complaint visit. It is a two story building with eighty-three (83) private and shared bedrooms, private and shared bathrooms, kitchen, dining area, common areas, activity areas, exercise room, offices, beauty salon, theatre, laundry room, and outdoor areas. It has an approved fire clearance for ninety (90) nonambulatory residents. Approved hospice waivers for five (05). Near the main entrance and mail room, LPA observed postings for confidential complaint contacts, Ombudsman contacts, emergency disaster plan, facility license and sketch, theft and loss policy, personal rights, rights of resident councils, admission agreement, transportation schedule, activity schedules, and daily menus. Walls, floors, windows, screens, and blinds were clean and in good repair. Coffee, water, and snacks were available near the lobby. Surveillance cameras were observed on the exterior and in common areas. The facility has two (02) elevators. Both were in working order. Resident mailboxes were located near the main entrance near staff offices. The laundry room was locked and contained two (02) operable washers, two (02) operable dryers, and detergents. Interview with the ED around 9:10 a.m. today revealed some cameras are used by families in resident rooms with no audio. Exits are secured with keypad locks. At approximately 9:30 a.m. LPA measured the room temperature to be 73 degrees Fahrenheit. The fireplace was appropriately covered. Hand sanitizer stations are posted throughout the facility on both floors. At approximately 9:40 a.m. LPA observed fully charged fire extinguishers on the first and second floor hallways which were last inspected on 10/11/24. Flashlights were also placed in each fire extinguisher housing for emergency lighting purposes. At approximately 9:45 a.m., smoke and carbon monoxide detectors within rooms were tested and deemed operational. Emergency exits were illuminated, unlocked, and free from obstructions. The facility has private and shared bedrooms. Bedrooms are furnished by residents and contain a chair, lamp, nightstand, storage, pull cords in the bedroom and bathroom, private bathrooms, and a bed with adequate bedding. All furnishings were clean and in good condition. The facility has private and shared bathrooms. Private bathrooms in rooms contained liquid soap, paper towels, trash cans with a tight fitting lid, grab bars near the toilet and shower pull cords, and a non-skid surfaces in the shower. All shared bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet, and pull cords. LPA observed an adequate supply of perishable, non-perishable, and emergency foods and water in the kitchen. Additional emergency water was stored in an upstairs storage closet. The hood was clean. Appliances were in good condition. Resident dietary cards were posted. At approximately 10:00 a.m., walk-in refrigerator and freezer temperatures were measured to be 39 and -12 degrees Fahrenheit, respectively. The dining room contained furniture in good repair, a suggestion box, and daily and alternate menus. A covered patio area adjacent to the dining room contained furniture in good condition, a designated smoking area, self-locking exits, and a gas grill. There was also a rose garden outdoor space available. At 11:10 a.m. and 12:10 p.m., call system pull cords were tested in first and second floor public restrooms. Staff responded within one (01) and two (02) minutes of each request. At approximately 11:15 a.m. and 12:15 p.m. LPA measured first and second floor water temperatures to be within regulatory range. The upstairs gym contained exercise equipment in good condition. The Beauty Salon, electrical rooms, janitorial closets, and storage closets were all locked an inaccessible. The theatre contained movies, television, and furniture in good repair. Board games, puzzles, art supplies, and reading materials were provided in upstairs and downstairs activity areas. A computer with internet, microphone, and camera was available for resident use on the second floor. The facility uses secured medication carts on each floor to assist with medications. The medication room is locked and contained medical records and a complete first aid kit with tweezers, scissors, bandages, and digital thermometer. A medication review was conducted at approximately 12:30 p.m. All prescription medications and controlled substances were present in correct quantities. At approximately 12:45 p.m. LPA reviewed the most recent fire safety inspection from 09/04/24. All fire safety systems passed inspection. All staff and resident files were complete and available for audit. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.