Routine inspection·February 29, 2024

At 10:30 a.m. on 02/29/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the Executive Director (ED) and disclosed the reason for the visit. A file review was conducted prior to the visit. The facility was last visited on 02/21/2024 for a complaint visit. It is a three-story building with one hundred eight (108) bedrooms in assisted living, nineteen (19) bedrooms in memory care, private and shared bathrooms, dining areas for assisted living and memory care, and indoor and outdoor common areas. It has an approved fire clearance for one hundred thirty eight (138) nonambulatory residents, of which eighteen (18) may be bedridden. The facility is currently in the process of increasing its capacity to 160. The facility serves residents with dementia. Approved hospice waivers for twenty-five (25). LPA and staff toured the facility inside and out at 11:45 a.m. The main entrance has automatic sliding doors and manual doors for entry. The walkway is covered, maintained, and free of hazards. Sanitizer and masks are available at the front. Sign-in sheets for guests and residents were observed. Behind the reception area, LPA observed postings for confidential complaint contacts, Ombudsman contacts, emergency disaster plan, COVID precautions, fire safety certificates, a recent licensing report, activity calendar, staff list, rights of resident councils, facility license, facility sketch with evacuation routes clearly labelled, administrator’s certificate, a blank copy of the admission agreement, personal rights, and the non-discrimination notice. At approximately 11:50 a.m. LPA observed fully charged fire extinguishers in the main hallways. They were last inspected on 10/30/2023. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. At 11:55 a.m., the walk-in refrigerator and freezer temperatures were recorded at 38 and -10 degrees Fahrenheit, respectively. Appliances were in good condition. Surfaces were sanitary. The food preparation area was free of chemicals and insects. The kitchen manager showed LPA temperature logs from January and February 2024. The assisted living dining room uses robots to bus away dirty dishes. A menu was posted out front. At 12:00 p.m. LPA measured the room temperature to be 70 degrees Fahrenheit. The activity room contained a television and theater-style seating, board games, puzzles, and sporting equipment. Bathrooms and showers contained grab bars, non-skid surfaces, liquid soap, paper towels, and trash cans. At approximately 12:05 p.m. and 12:20 p.m. LPA measured the water temperature in bathrooms on the first and second floors to be 105.0 and 106.8 degrees Fahrenheit. The memory care unit contained a separate dining room, indoor and outdoor activity areas, and a television room with furniture in good repair. The entrance requires a code and exits used 15-second delayed egress measures which were tested and functional at 12:10 p.m. LPA observed a shared room with sufficient space, television, a chair, and beds with sufficient and clean linens. A sign was posted stating “No smoking – Oxygen in use”. LPA observed three (03) bedrooms on the first and second floorfloors of the assisted living unit. Both bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. The pull cord to the call system was tested at 12:13 p.m. in Room 103. By 12:14 p.m., staff responded to the call. Signs were posted in the upstairs and downstairs rooms showing staff cleaned the room and provided laundry services on a designated day of the week. Walls, floors, windows, screens, and blinds were clean and in good repair. A café at the front contained seating and food and drink items. The lounge area at the main entrance contained ample seating with furniture in good condition and a grand piano. Staff stated a pianist comes to the facility once a week to perform. Staff were observed playing card games with residents around 2:00 p.m. LPA observed a musician perform for residents at 2:30 p.m. LPA conducted medication checks in the assisted living and memory care medication rooms at 12:35 p.m. and 2:30 p.m. LPA reviewed and staff counted quantities of three (03) residents’ medications and controlled narcotics. All medications were accounted for and matched the digital records. Both rooms were locked from the outside. The facility uses medication carts to dispense medications. A minor repair was noted in the ceiling outside of the assisted living medication room. A locked laundry area contained four (04) washing machines and four (04) dryers. Detergent was stored in a locked storage area. All emergency exit paths were free from obstructions. Exit doors and gates were unlocked. At approximately 12:40 p.m. Emergency stair chairs were observed at the top of each stairwell. Roof access was inaccessible in a stairwell due to a locked gate. At approximately 12:40 p.m., smoke and carbon monoxide detectors were tested and operational. LPA toured the third floor with staff. The third floor was only accessible by elevator and required a key. The third floor served as storage and also had a camera area. LPA and ED reviewed the Compliance and Regulatory Enforcement (CARE) Tools at 2:45 p.m. today. Due to time constraints, LPA will return on 03/01/2024 to conduct staff and resident interviews and complete record review on an LIC 809 Case Management – Annual Continuation form. 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.