Routine inspection·September 12, 2025

On Friday, 09/12/25, Licensing Program Analyst, (LPA) Raymond Comer, arrived unannounced to conduct an annual inspection of the Facility. LPA met with Administrator, and reason for the visit was disclosed. Facility is licensed as a six (6) floor complex and top floor penthouse. Fire clearance approved for (110) non-ambulatory residents, and ten (10) bedridden. Hospice waiver approved for fifteen (15) residents. At the time of this inspection, fifteen (15) residents are receiving hospice care services, and two (2) residents are bedridden. At 8:40 am, LPA conducted a tour of the physical plant and observed the following: Physical plant was inspected for cleanliness and condition . Facility’s main doors are the primary entry/exit access. Screening area is located immediately upon entrance. As the Facility provides dementia care, LPA observed the delayed egress system working properly. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 74.0°F., within the required range. The facility maintains an approved Mitigation and Infection Control Plan. Required postings are prominently displayed and observed to be current. [Continued on LIC 809C] Resident records: A total of seven (7) Resident files were reviewed for current IPP and/or needs and services plans, physician report, admission agreements, pre-admission appraisals\reappraisals, centrally stored medication logs, and resident identification. Resident records appeared to be complete and current. Due to time constraints, LPA was unable to complete the required Annual inspection visit. LPA will complete at a later date. Exit interview conducted/Copy of report was provided.