Routine inspection·May 29, 2024

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Executive Director James Craddock, who's Administrator's certificate expires on November 8,2024, and explained the reason for the visit. LPA and the Executive Director toured the facility. The facility is composed of two buildings connected by a hallway. The main building (building B) is 3 stories and houses the memory care unit on the second floor. The secondary building (building A) is two stories. Building B has an interior outdoor courtyard with a water fountain. LPA observed the PUB 475 poster (See Something, Say Something) is posted in the main entrance of the facility. LPA observed during the tour that all 4 stairways had emergency evacuation chairs. LPA observed each floor of each building had a working carbon monoxide detector. LPA observed all fire extinguishers are fully charged. LPA observed that the smoke detectors in all 10 rooms that were inspected were operational. LPA measured the hot water in rooms inspected. Hot water measured between 109.0 degrees Fahrenheit to 112.6 degrees Fahrenheit. LPA observed all resident rooms had the required furnishings. LPA observed the fireplace in the resident library is screened. LPA and the Executive Director toured the dining room and kitchen. LPA observed a 2-day perishable and a 7-day nonperishable food supply on hand in the kitchen. LPA observed the kitchen is clean and organized. LPA observed the emergency food stored in a supply closet and the emergency water supply is stored in a storage room. LPA and the Executive Director toured the second floor memory care. LPA observed the medication cart is locked and kept in the life guidance med room. LPA tested the delayed egress doors in memory care unit. Both delayed egress doors tested operational. LPA observed shaded outdoor seating next to the dining room and in the interior courtyard. No obstacles or hazards observed inside or outside of the facility. During the visit LPA observed residents participating in bingo in the activity room. LPA interviewed 6 staff and 7 residents. LPA reviewed 6 staff files. All staff files reviewed had the required training. No discrepancies observed in the staff files. LPA reviewed 7 resident records and medications, no discrepancies were observed. The last fire drill was conducted on May 13, 2024. LPA consulted with the Executive Director regarding reporting requirements. No deficiencies are being cited as a result of this visit. An exit interview was conducted with Executive Director and a copy of the report provided. LPA consulted with the Executive Director regarding reporting requirements. No deficiencies are being cited as a result of this visit. An exit interview was conducted with Executive Director and a copy of the report provided