Routine inspection·July 24, 2025

On 07/24/25, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Annual Visit to the facility listed above. LPA met with Business Office Director, Amber Lambert, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is licensed to serve 115 non-ambulatory residents aged 60 and over, of which 8 may be bedridden. The facility has an approved hospice waiver for 20. Physical Plant/Structure The facility is a five-story structure located in a commercial neighborhood. The ground floor is the car park and entrance, the first and second floors are Assisted Living, the third floor is Memory Care, and the fourth floor is Memory Care. There is a total of 37 Assisted Living units and 61 Memory Care units, each unit contains a bathroom. On the first floor there are 3 common bathrooms, beauty salon, 2 common areas with a TV, computer area, dining area, bistro area, industrial kitchen, storage rooms, laundry room, offices, and staff break room. The second floor consists of an activity room/theater room, bistro, wellness center, laundry room, staff offices, and storage rooms. The third and fourth floor consist of a kitchen, dining room, activity room, TV room, shaded outdoor patio, staff offices, storage room, and laundry room. During the tour, LPA did not observe any bodies of water on the premises. The outside patio/garden area has a shaded area with tables and chairs. The gates exiting the patio are egressed, and work properly. All outside walkways were observed to be clean, clear, and free of obstructions, debris, and hazards. All windows, screens, curtains, and blinds were observed to be in good repair and operate properly. Rooms LPA inspected eight (8) resident rooms, 117, 125, 204, 215, 304, 321, 403, and 412 and observed them to be clean and in good repair. LPAs observed the rooms have the required furniture including a bed, dresser, nightstand, chair, and storage space for personal belongings. Residents have the option to furnish their room, or the facility has furniture available if residents require it. LPA observed the beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. Residents do have the option to use their personal linens, or the facility has a supply available. LPA observed an additional supply of linens in a storage room. All linens and mattresses were observed in good condition. All rooms were observed to have ample lighting. Bathrooms LPA observed all bathrooms to be operable and within Title 22 regulations. The toilet, facets, and shower work properly. The bathrooms were observed clean. The showers were observed with secured safety handrails, nonskid mats, and a shower chair. The showers were observed to be free of mold and mildew. LPA observed storage space for residents’ hygiene products. LPA observed an ample supply of towels and hygiene products available for residents or residents have the option to supply their own. The water temperature in rooms inspected and bathrooms in common areas measured between 108-degrees and 115.4-degrees Fahrenheit. Kitchen LPAs observed the industrial kitchen to be clean and sanitary during the time of visit. LPA observed all appliances to be operable and in good repair. LPA observed an ample supply of cookware, dishware, and cutlery. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All foods were observed properly dated, labeled, packaged, and stored. The freezer temperature measured 0-degrees Fahrenheit, and the refrigerator temperature measured 45-degrees Fahrenheit. LPA observed knives and sharps to be secured and are inaccessible to residents. LPA observed a menu posted in the dining room. The menu and kitchen were last reviewed and inspected by a dietitian on 06/25/2025. The third and fourth floor kitchens were observed to be clean and sanitary. LPA observed a supply of snacks and drinks available for residents at any time LPA observed cleaning supplies and sharps to be secured in a locked storage room and are inaccessible to residents. All trash cans were observed with tight fitting covers. Common Rooms LPA observed the facility was appropriately furnished during the time of the visit. LPA observed all common rooms to have ample seating to accommodate residents. LPAs observed all dining rooms to have ample seating to accommodate residents. In the activity room, LPA observed arts, crafts, games, puzzles, and reading material available for residents. LPA observed a daily and monthly activity schedule. All walkways, hallways, and stairs in the facility were observed to be clean, clear, and free of hazards and obstructions. The facility was kept at a comfortable temperature of 72-degrees Fahrenheit. All rooms and hallways were observed to have ample lighting. Files LPAs observed resident files secured in the locked wellness room and are inaccessible to residents. LPA reviewed the files for eight (8) residents and observed they have the required documents. The staff files are secured in the business office and are inaccessible to residents. LPA reviewed the file for the the Administrator and six (6) staff and observed they have the required documents, certification, clearance, and training. LPA Observed the administrators Administrator Certificate is valid till 08/02/2025. LPA informed Business Office Manager that Licensing fees are due on 07/24/2025 and provided the PIN. Safety LPA obseved smoke detectors on each floor and carbon monoxide detectors in each resident unit and found them to be operable. When smoke detectors are triggered they close. LPA observed multiple fully charged fire extinguisher last serviced on 12/03/2024, throughout the facility. The last Fire Prevention Inspection was conducted on 05/07/2025. The last emergency drill was conducted on 06/27/2025. LPA observed evacuation chairs at each staircase. The facility has a working landline telephone. LPA observed the facility’s Emergency and Disaster Plan posted and last updated on 03/31/2025. LPA observed all required posting, posted throughout the facility. LPA received and reviewed a copy of the liability insurance through Acord valid till 05/01/2026. Medications LPA observed medications secured in locked medication carts, secured in locked medication rooms. Medications are inaccessible to residents. LPA observed medications to be in their original packaging. LPA reviewed the medications and Medication Administration Record (MAR) for six (6) residents. LPA observed six (6) out of six (6) resident’s medications are consistent with properly documented records. LPA observed a fully stocked First Aid kit with a current manual, in the wellness room. LPA observed additional First Aid supply secured in a storage room. Infection Control LPA observed a sanitizing station upon entry, in the restrooms, and throughout the facility. LPA observed required infection control signs posted throughout the facility. LPA observed a 30-day supply of Personal Protective Equipment (PPE). During today's visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Business Office Director, Amber Lambert, and Regional Health Services Director, Jennifer Frost, and a copy of this report was provided.