Routine inspection·February 17, 2023

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required Annual Visit focusing on COVID-19 Infection Control Practices. LPA was met by Administrator Sherry Fischer and explained the purpose of the visit. Staff #1 (S1) later joined LPA and Administrator Fischer to assist with tour of physical. This is a 5-story building located on a main intersection. This facility is licensed to serve residents over 60 years old. This facility has an approved Dementia Care Plan in its plan of operation and accepts/cares for residents with dementia. The facility has a fire clearance approved for 150 non-ambulatory residents of which 15 may be bedridden. Garden House (Memory Care Unit) is approved for delayed egress, secured perimeter, and secured locked perimeter. Hospice Waiver approved for 15 residents. There are a total of 111 apartments, 13 of those in memory care unit and 2 of those 13 apartments will be shared. The facility has central air and heating accommodations LPA OBSERVATIONS: · 1 st floor consisted of Garden House (Memory Care Unit), Dining room, Lobby, Activity room,Administration office, Theater, Wellness room and Salon. Garden House entrance is only accessible by pin pad access. LPA observed a kitchenette and living room area. Signage promoting cough/sneeze etiquette was observed in various locations throughout this area. Resident rooms have signal systems located in each bathroom and facility phones to call the front desk. The signal system was tested and is operable. Extra supply of chemicals and cleaning supplies are kept in a maintenance office located on the 1st floor and was observed to locked and inaccessible to residents. Kitchen area was observed after lunch time. The walk in refrigerator was observed to be at 45 degrees Fahrenheit and the walk freezer at 0 degrees Fahrenheit. LPA observed sufficient 2-day perishables and 7-day non-perishable foods as required. LPA observed perishable foods stored in covered containers at the appropriate temperatures. No pesticides or poisons were stored in the food areas. Storage areas for cleaning solutions, toxins, knives, and hazardous items were secured and made inaccessible to residents. · 2 nd floor consisted of 34 resident rooms. Resident room #201 was observed to be clean and contained the required furnishing and linens. Water temperature in this bathroom was measured at 118.9 degrees F which is in the required 105 – 120 degrees F. Resident room #203 was observed to be clean and contained the required furnishing and linens. Water temperature in this bathroom was measured at 119.8 degrees F which is in the required 105 – 120 degrees F. Grab bars were observed near toilets and showers. Emergency pull cords were observed in every resident apartment. · 3 rd floor consisted of 34 resident room. Resident room #305 was observed to be clean and contained the required furnishing and linens. Water temperature in this bathroom was measured at 120.0 degrees F which is in the required 105 – 120 degrees F. Resident room #315 was observed to be clean and contained the required furnishing and linens. Water temperature in this bathroom was measured at 117.5 degrees F which is in the required 105 – 120 degrees F. Grab bars were observed near toilets and showers. Emergency pull cords were observed in every resident apartment. · 4 th floor consisted of 24 resident rooms. Resident room #412 was observed to be clean and contained the required furnishing and linens. Water temperature in this bathroom was measured at 116.6 degrees F which is in the required 105 – 120 degrees F. Resident room #422 was observed to be clean and contained the required furnishing and linens. Water temperature in this bathroom was measured at 118.2 degrees F which is in the required 105 – 120 degrees F. Grab bars were observed near toilets and showers. Emergency pull cords were observed in every resident apartment. · 5 th floor consisted of 10 resident rooms. Resident room #506 was observed to be clean and contained the required furnishing and linens. Water temperature in this bathroom was measured at 119.3 degrees F which is in the required 105 – 120 degrees F. Resident room #510 was observed to be clean and contained the required furnishing and linens. Water temperature in this bathroom was measured at 119.8 degrees F which is in the required 105 – 120 degrees F. Grab bars were observed near toilets and showers. Emergency pull cords were observed in every resident apartment. A shaded area with chairs is provided to the residents was observed on the roof. · Several fire extinguishers were observed throughout the facility. Smoke detectors were observed throughout the facility along with attached carbon monoxide detectors. Doors, exits, hallways, and passageways were clear and free of obstruction. There are no pools or bodies of water in or around the facility. Extra PPE supplies were secured inside Resident Care Office. Several first aid kits were observed throughout the facility which included all required supplies. Last fire drill was conducted on 02-16-23 at 6pm. Administrator certificate (6025678740) for Sherry Fischer was observed and expires on 03-12-23. No deficiencies were observed during visit. An exit interview was conducted, and a copy of this report was provided to the Administrator Fischer .