Routine inspection (multi-day)·May 30, 2025

Today, Friday 5/30/25, Licensing Program Analyst, (LPA) Raymond Comer, made an unannounced site visit to continue required 1 Year annual Inspection, initiated on 05/29/2024. LPA met with Administrator, Lori McKay, and the purpose of visit was disclosed. The remaining inspection domains were observed, reviewed and inspected : Medications : Located on the second floor, medication room is secured. locked, and inaccessible to residents. Medications are listed on a centrally stored medication and destruction record log. LPA audit of resident medications, with corresponding Medications Administration Record, (MAR) found records as accurate. First Aid kits, located in cabinet storage, were observed as fully stocked. Bedrooms: LPA observed random bedrooms (Rooms #104, #107, #109, #202, #203, #206, #209) finding them as clean, with sufficient lighting, bed linens, at least one chair, night stand, closet space, and dressers. Signaling system was tested in random bedrooms and working properly. Average staff response time to activated signal was within three minutes. Bathrooms: LPA observed bathrooms to be clean and sanitary, with required safety fixtures. (grab bars, anti-slip floor stripping) Hot water temperature measured between 115.°F. and 118.°F; within the required range. Hand towels are not shared. [LIC-809C]-continued Outdoor: Courtyard observed to have a shaded patio area, with a table, and sufficient seating for residents. Outdoor furniture observed to be in fair condition. Multiple sheds in the outdoor area contain tools, supplies, and PPE. All outdoor sheds were observed as locked and inaccessible to Residents. All trash cans were covered. There are no bodies of water in the facility. Resident records: LPA observed records stored in a locked and secured records room on the first floor, inaccessible to residents. Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be current and complete. Staff records: LPA observed records stored in a locked and secured records room on the first floor, inaccessible to residents. Criminal record clearances were present, and Staff are associated to this facility. Staff records appear to be complete and current. However, upon LPA review of Staff roster, and conversation with Administrator, LPA was informed that facility does not have an Activities Director. LPA interviewed three (4) staff that confirmed there is no Activities Director; it was stated to LPA that the previous Activities Director left their position in April of 2024. An exit interview was conducted; deficiency cited on LIC 809-D. Appeal rights discussed, and a copy of the report was provided to the Administrator.