Routine inspection·April 12, 2022

Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility for the purpose of conducting a Required - 1 Year Annual inspection, with an emphasis on Infection Control due to the COVID-19 pandemic. LPA Martinez was screened upon entry into the facility. LPA met with Executive Director James Craddock and reason for the visit was explained. ED Craddock confirmed there are currently no cases or exposures of COVID-19 within the facility. ED Craddock's Administrator Certificate expires on 11/8/2022. LPA toured the facility with ED Craddock. Facility has 108 Residents in care during today's visit with 12 Residents receiving Hospice care. Facility consists of Assisted Living with a Memory Care on the 1st floor. LPA observed Fitness Room, Salon/Spa, Multi-Use/Activity Room, Theater, Bistro, Dining Room, Kitchen, and a private Dining Room on the first floor; the Library on the 2nd floor, and Art Studio and a Sky Lounge on the 3rd Floor. LPA observed Residents relaxing, walking around and/or having lunch. Residents appeared happy and well taken care of. Facility appears clean and sanitary. Resident rooms have the required elements as well as common bathrooms were stocked with soap, sanitizer and paper towels. Rooms are single occupancy in Assisted Living and Memory Care. Visitors are screened using a questionnaire. LPA observed the screening/sanitizing station at the entrance of the facility. Facility does temperature check and has a sign-in log sheet. Facility takes resident and staff temperatures daily and documents. First Aid kit has all required items. Mitigation Plan has been approved. Facility has emergency evacuation chairs at the top of stairwells. LPA observed an ample supply of emergency food and water. LPA observed outside visitation area. LPA observed the Medication Room and facility uses electronic medical records for medication management. Facility has a plan for COVID testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed select resident files during the visit and files are up to date including emergency information. Most residents and staff are vaccinated for COVID-19. All required Department poster were observed. No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report will be emailed to ED.