Routine inspection·September 26, 2024

Licensing Program Analysts (LPA) Elizabeth Irra conducted an annual inspection visit. LPA met with Adriane Runge and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility has an Infection Control Policy (binder) in place. Operational Requirements: Facility is adhering to the operational requirements. This facility is approved for (97) non-ambulatory residents (7 of which may be bedridden and 15 of which may be under hospice). There are currently (47) residents in the assisted living facility and (25) memory care residents. Physical Plant & Environment Safety: LPA toured facility grounds. Fire smoke alarms and carbon monoxide detectors observed. The fire extinguishers are located throughout the facility and appear to be full (last service date 03/27/24). Signal system tested and operable. Last emergency drill was conducted on 08/29/24. Emergency evacuation chairs were observed at the stairways. Hot water temperature measured within regulations. The hot water supply measured at the following temperatures: 106.5* to 110.0*. Bathrooms have non-skid surfaces and grab bars. Staffing : Facility is adhering to staffing requirements. Refer to LIC 809C for the continuation of this report. Personnel Records-Training : Staff files are maintained at the facility. LPA reviewed staff files for S-1 through Staff #5 (S-5). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights. Resident Rights-Information: Resident rights are posted and included in Resident files. Planned Activities: This facility has an activity room and provides a variety of activities for the residents. Activity schedule is posted. Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Posted menu observed. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining areas have adequate seating in both the assisted living and memory care dining rooms. Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #7 (R-7). Resident files are maintained at the facility. Resident files have the required documents. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Assessment Summary, Resident Rights were observed. Disaster Preparedness: The facility has a Disaster Preparedness manual (binder) in place. Health Related Services/Incidental Medical Services: The medications are stored and locked (medication carts) inside the medication room. Exit interview conducted, copy of appeal rights and a copy of this report was provided to Adriane Runge.