Routine inspection·April 18, 2024

At 9:15 a.m. on 04/18/2024, Licensing Program Analysts (LPAs) Nicholas Reed and Leizl de la Cerra conducted an unannounced annual inspection. LPAs met with staff and later the administrator and disclosed the reason for the visit. LPAs conducted a file review at 10:00 a.m. of staff and personnel files. LPAs toured the facility inside and out at 11:00 a.m. The facility was last visited on 03/08/24 for a complaint visit. It is a three (03) story building with a capacity of 176 residents. LPAs observed bedrooms, shared and private bathrooms, kitchen area, dining areas, garage, common areas, activity rooms, offices, and a courtyard. It has an approved fire clearance for 176 nonambulatory residents, of which fifty (50) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for thirty (30). At the main entrance, LPA observed a designated smoking area near the street. A doorbell was posted at the front for after-hours entry. Postings were observed inside for COVID precautions, emergency contacts, Ombudsman contacts, confidential complaint contacts, facility license, facility sketch, emergency disaster plan, administrator certificate, personal rights, rights of resident and family councils, theft and loss policy, nondiscrimination notice, and activity calendar and reminders. Walls, floors, windows, screens, and blinds were clean and in good repair. An activity room near the reception desk had a television, exercise equipment, and sufficient activity space. Activities were observed and conducted at 9:30 a.m., and a live musical performance occurred at 10:30 a.m. At 11:35 a.m., LPAs measured the first floor temperature to be seventy-six (76) degrees Fahrenheit. The reception area including seating, an administrator office, a business office, and mailboxes. Personnel files were stored and locked in the business office. At 12:55 p.m. LPAs observed a fully-charged fire extinguisher. It was last inspected on 06/30/2023. LPAs and administrator toured Room 117 at 1:00 p.m. and measured the hot water temperature to be 107.6 degrees Fahrenheit. At 1:05 p.m. the smoke and carbon monoxide detector was tested and operating. At 1:10 p.m. the pull cord system was tested. Staff arrived by 1:11 p.m. The second floor contained a medication room, activity room, and resident rooms. The medication room contained a fully-stocked first aid kit, inaccessible medications, and locked medication carts. The activity room contained reading material, games, puzzles, and exercise equipment. Room 205 was inspected at 1:15 p.m. The bedroom area contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. The water temperature was measured at 1:20 p.m. to be 114.3 degrees Fahrenheit. The smoke detector was tested to be operational. The pull cord system was tested at 1:25 p.m. Staff arrived in less than thirty seconds. Fire doors were observed in the middle of the hallway. Water and coffee was available on the first and second floors. The third floor was occupied by only one (01) resident. Room 314 was inspected at 1:30 p.m. The water temperature was measured at 113.6 degrees Fahrenheit. Private bathrooms on all three floors contained liquid soap, paper towels, trash cans, grab bars near the toilet and shower, and a non-skid mat in the shower. The courtyard contained maintained plants and trees. Two (02) shaded seating areas were in good repair. The walkway was free from debris and tripping hazards. LPAs observed three (03) dining areas near the kitchen. The kitchen contained an adequate supply of perishable and non-perishable foods. The dishwashing area was free of debris and vermin. Appliances were in good condition. Cleaning solutions and sharps were inaccessible. At 2:00 p.m. the walk-in freezer and refrigerator temperatures were measured to be -9 and 32 degrees Fahrenheit. A washing machine and dryer were located in the laundry room. Both were in working order. Detergents were stored in the room which was locked when staff are not present. All emergency exit paths were free from obstructions and unlocked. All electrical rooms, maintenance rooms, roof access doors, and rooms with cleaners were locked. LPAs observed two (02) rooms with signs stating “No smoking-Oxygen in use”. The garage was free of hazards. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.