Inspector’s narrative
What the inspector wrote
At approximately 10:30 a.m. on 04/30/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and Vice President of Operations (VP) and disclosed the reason for the visit. The Regional Director of Operations later joined the visit at approximately 1:00 p.m. Due to time constraints, LPA returned to the facility today at approximately 9:30 a.m. and finished the inspection with the administrator and VP.
A file review was conducted prior to the visit.
The facility was last visited on 03/18/25 for a complaint visit. It is a three (03) story building with a capacity of 176 residents. LPA observed bedrooms, shared and private bathrooms, kitchen and 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. Approved hospice waivers for thirty (30).
Between 10:30 a.m. and 3:30 p.m. on 04/30/25 and between 9:30 a.m. and 11:00 a.m. today, LPA, administrator, and VP toured the facility. At approximately 10:00 a.m. on 04/30/25 the facility telephone was called and deemed operational. At 1:30 p.m. on 04/30/25, a medication review was conducted for nine (09) residents. All medications quantities were maintained and documented in the correct amounts. At 3:30 p.m. on 04/30/25, LPA conducted a file review for resident and personnel records. All files were complete and available for audit. LPA also reviewed the most recent fire safety inspection from 11/26/24 in which all systems passed. The most recent fire safety drill was conducted on 04/26/25. Liability insurance and surety bond were both current.
At the main entrance, LPA observed a designated smoking area. A doorbell was posted at the front for after-hours entry along with a sign with two (02) phone numbers listed. The designated smoking area at the front contained artificial shrubs and an umbrella for shade. 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, normal and alternate menus, and activity calendars and reminders. Walls, floors, windows, screens, and blinds were clean, free from stains, and in good repair.
An activity room near the reception desk had a television, exercise equipment, a piano, a sound system, and sufficient activity space. Activities were observed and conducted at 10:00 a.m. today and yesterday, and a live musical performance occurred around 10:30 a.m. today. The reception area including seating, board games, an administrator office, a business office, and mailboxes. Personnel files were stored and locked in the business office.
At approximately 11:00 a.m. on 04/30/25, a fully-charged fire extinguisher was observed near the main entrance. It was last inspected on 06/12/24 and inspected by facility staff every month thereafter. At 11:10 a.m on 04/30/25 the room temperature was measured to be 71 degrees Fahrenheit.
Rooms 101, 110, 219, and 209 were inspected. All four (04) rooms contained functional smoke alarms, appropriately furnished bedding, chairs, nightstands, storage, lighting, and bathrooms with paper towels, liquid soap, grab bars near the toilets and showers, and non-skid mats or strips in the shower. All rooms were clean and in good repair. Call systems in the rooms were tested and deemed operational. Staff attended to the calls within one (01) to ten (10) minutes. Water temperatures in bathrooms were measured to be between 105.4 and 109.8 degrees Fahrenheit.
The second floor contained a medication room, activity room, and more resident rooms. The medication room contained a fully-stocked first aid kit, inaccessible medications, and locked medication carts with secondary locks for controlled substances. The activity room contained reading material, games, puzzles, and exercise equipment. Fire doors were observed in hallways. Fire sprinklers were observed throughout the building. Water and coffee was available on the first and second floors.
The third floor was unoccupied. The rear elevator accessed the third floor but was inoperable. The facility has scheduled maintenance and informed The Department of all updates. A final inspection is set for 05/02/25. Two (02) out of two (02) stairwells had emergency evacuation chairs at the tops of the stairwells. No hazards were observed in stairwells or emergency exit paths. All emergency exits were unlocked. All electrical rooms, maintenance rooms, and roof access doors were locked. The garage was free of hazards. The courtyard contained plants and trees and two (02) shaded seating areas.
LPA observed three (03) dining areas near the kitchen. The kitchen contained an adequate supply of perishable, non-perishable, and emergency foods. The dishwashing area was free of debris and vermin. Appliances were in good condition. Cleaning solutions and sharps were inaccessible. At approximately 10:10 a.m. today, the walk-in freezer and refrigerator temperatures were measured to be -8 and 32 degrees Fahrenheit. Temperature and maintenance logs were observed near appliances. Two (02) washing machines and two (02) dryers were located in the laundry room. Both were in working order. Detergents were stored and locked.
During yesterday’s and today's inspection, the facility was in compliance with Title 22 regulations. No immediate health or safety hazards were observed.
Exit interview conducted. Copy of report provided.
