Routine inspection·June 18, 2024

Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility at 9:30am to conduct Annual inspection. LPA was greeted by front the receptionist, who notified the Executive Director (ED) April Princesa, and who was informed the reason of the visit. The entire facility has (3) floors, which is licensed for (160) non-ambulatory, of which (67) may be bedridden on the 1 st and 2 nd floor of villas 1 & 2. There is a hospice waiver for (13), and fire clearance approved for delayed egress for the Memory Care, located in villa 2. The current census is 132. Facility license/sketch, rights of resident council, grievance/complaint procedures, emergency disaster plan, resident bill of rights, personal rights, rights of resident council, discrimination notice, theft and loss policy, activity schedule, and evacuation plan visibly posted. Common areas: LPA conducted a physical plant tour with (ED) April, and inspected the first floor, which identifies front entrance lounge with a hospitality station with coffee, water, and tea. The Administration offices, beauty salon, resident’s rooms, and laundry were also observed. All areas were clean and appropriately furnished for resident’s comfort. Passageways were free from obstruction, and inside temperature was comfortable. The second and third floor consists of resident rooms, activity, fitness, snack room, mail room, and personal laundry equipment for residents. The third floor also has movie and game room, and library. Dining Room: Passageways were free from obstruction, with adequate lighting. There is a daily menu placed on the table, with chairs and table were comfortable and clean. LPA observed residents eating a variety and healthy food for lunch. Coffee, tea, and water is available throughout the day, as well as a variety of snacks. Resident Rooms : All apartments are provided with a microwave and refrigerator purchased by the facility. Rooms, floors, walls, and carpet areas were clean in good repair. Residents can have pets, and during inspection, LPA observed cats and dogs signs posted on resident's doors. Thermostat, smoke alarms, and carbon monoxide detectors were being tested during the inspection, hired by Johnson Control Inc, (JCI) company. Bathrooms: All were clean, with grab bars, non-skid mats, and shower chairs. There are emergency pull cords located by the toilet for emergency purposes. Residents also have emergency pendants. Water temperature was measured in several of the rooms. Memory Care Unit : Is located adjacent to the Assisted Living facility. It has (3) floors, with a delayed egress front door and keypad lock located outside the facility. The current census is (38). Rooms are either private or separated, with (1) shared bathroom. All common areas were clean and in good repair. Passageways were free from obstruction, and furnishings were appropriate for residents. There is a dining room, kitchen, and activity room for resident’s entertainment and comfort. Snacks, water, and tea are available throughout the day. Meals are prepared by the main kitchen and delivered to the unit. Smoke alarm and carbon monoxide detectors are in each resident room. . Record Review : Medication room was locked and inaccessible to residents. There is a complete first aid kit at the facility. Residents and staff records were reviewed. LPA reviewed files of randomly selected residents. Files included signed admission agreements, current appraisals, current medical assessments, physician orders for medications and centrally stored medication logs. Medications appear to be given as prescribed. Residents files appear to be complete and updated. Staff present files were also reviewed, staff files appear to be complete and updated training is computerized. First aid and medication training current. No health and safety hazards noted during the visit. **Note, inspection tool questions for staff and residents did not populate and LPA was not able to complete them. Exit interview conducted and copy of report provided to Administrator.