Routine inspection·March 10, 2025

Licensing Program Analysts (LPAs) Alberto Lopez and Sakinah Madyun conducted an unannounced required annual inspection. LPA met with Assistant Director Ruth Diehl and explained the purpose of the visit. The facility is licensed as a Continuing Care Residential Community (RCFE-CCRC) to serve 518 residents, 60 years and above, of which 259 may be non-ambulatory. The hospice waiver is approved for 10 residents. There are currently 31 Assisted Living residents, 3 residents in the Memory Care unit, 66 residents in Skilled Nursing, and 254 residents in Independent Living. LPAs toured the community with the Assistant director for the Assisted Living and Memory Care units, in addition to some of the common areas of the facility. The Assisted Living unit and Memory Care unit are detached from the main building. The Assisted Living unit consists of 32 individual apartments with their own bathrooms and a shared dining area. The Memory Care unit consists of 4 bedrooms, one TV room, 1 full bathroom and ½ bathroom, living room, dining room, small visiting room and kitchen. There is an alert system installed at all the doors. Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and have an infection Control Plan at facility. Operational Requirements: The facility does accept patients with dementia. There 0 bedridden residents residing at the facility. The facility has enough liability insurance covering injury to residents and guest. (continued on 809C) (continued from 809) Physical Plant & Environment Safety: There is a pool on the premises, and it is secured as required. Facility has operable smoke and carbon monoxide detectors located in each room and hallways. Knives were locked and inaccessible to residents. Cleaning solutions were not locked in the common laundry area and accessible to residents. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in random resident’s bathrooms and laundry room and were measured between 107.6 -112.4 degrees F which is within required range of 105-120 degrees F. Skid mat was missing in room #27 Deficiencies cited on 809D, exit interview conducted and copy of report and appeal rights provided. Due to time constraints, LPA will return another day to complete annual inspection.