Routine inspection·January 15, 2025

At 9:30 a.m. on 01/15/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit. A file review was conducted prior to today’s visit. At 9:45 a.m., LPA reviewed resident personnel files. All files were complete and available for audit. The facility was last visited on 12/27/2024 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. The facility serves residents with dementia. Approved hospice waivers for twenty-five (25). Cameras are used in common areas. The main entrance has automatic sliding doors and manual doors for entry. The walkway is covered, maintained, and free of hazards. Sign-in sheets for guests and residents were observed. Postings for confidential complaint contacts, Ombudsman contacts, emergency disaster plan, COVID precautions, fire safety certificates, daily and monthly activity calendars, daily and weekly menus, staff list, rights of resident councils, personal rights, facility license, facility sketch with evacuation routes clearly labelled, administrator’s certificate, and a blank copy of the admission agreement were observed behind the reception area. At approximately 1:35 p.m., the house telephone was called and deemed operational. Fire sprinklers and fire extinguishers were observed throughout the building and on both floors. At approximately 1:50 p.m. LPA observed fully charged fire extinguishers which were last inspected on 10/18/2024. The facility call system was tested at 2:15 p.m. in Room #105 and at 3:00 p.m. in the Memory Care bathroom. Staff responded within four (04) minutes of each test. At 2:20 p.m., the smoke and carbon monoxide detector in room #105 was tested and deemed operational. At 2:22 p.m., the hot water temperature in the restroom of room #105 was measured to be 118.8 degrees Fahrenheit. At 2:55 p.m. the room temperature was measured to be 71 degrees Fahrenheit. At 2:57 p.m., the rear exit to the Memory Care portion of the facility was tested. The delayed egress alarm sounded for about fifteen (15) seconds. The main activity room contained games, appropriate seating, and reading materials. Around 3:00 p.m. residents were observed singing karaoke. Around 3:05 p.m. LPA observed about five (05) residents in the memory care section engaged in a painting activity. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. The kitchen was locked form the outside and inaccessible to residents. At 3:15 p.m., the walk-in refrigerator and freezer temperatures were recorded at 40 and -2 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 dietary restriction cards of residents. LPA inspected three (03) bedrooms on the first and second floors. Bedrooms all contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Signs indicating “No Smoking: Oxygen in Use” were posted. Private and shared bathrooms and showers contained grab bars, non-skid flooring, liquid soap, and trash cans. 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. LPA conducted medication reviews in the assisted living and memory care medication rooms between 2:45 p.m. and 4:00 p.m. Five (05) out of five (05) supplies of routine medications and controlled narcotics matched the dates and records. All medications were accounted for and matched the digital records. Both medication rooms were locked from the outside. The facility uses medication carts to dispense medications. A locked laundry area contained four (04) washing machines and four (04) dryers. Detergents were stored in a locked storage area. All storage areas and maintenance rooms were inaccessible. All emergency exit paths were free from obstructions. Exit doors and gates were unlocked. Emergency stair chairs were observed at the top of each stairwell. Roof access was inaccessible in a stairwell due to a locked gate. At 4:45 p.m., LPA reviewed fire safety inspections from 11/26/24. 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.