Routine inspection·November 1, 2024

On 11/1/2024, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. Executive Director (ED) Jill Johnson was present to assist with the facility inspection on today's date. The facility is licensed for one hundred fifty (150) non-ambulatory residents with approved hospice waiver for fifteen (15) residents and fifteen (15) Bedridden. Currently, there are three (3) Hospice residents present during today’s visit. This is a three story with attached Memory Care facility . The facility is 121 private apartment facility. There are 112 residents present during facility visit. At around 10:16AM, LPA conducted a tour of the physical plant accompanied by Executive Director, and the following was observed: There were no bodies of water on the premises. All resident rooms observed met department regulations. LPA inspected 15 resident rooms. Resident beds and bedding supplies were in operational condition, lighting was provided, and storage for the residents personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. LPA checked water temperature in 9 resident Bathrooms and found water temperature measured between 106.5 to 115.3 degrees F. A comfortable temperature of 78 degrees F. was maintained in the facility. LPA observed the facility to be furnished at the time of the visit. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. LPA observed emergency food and water supply. Facility has 5 drums of emergency water. Facility has Easy meal kits that feed 25 individuals per kit. LPA observed 25 boxes of meal kits. LPA observed eight fire extinguishers all mounted and fully charged. A review of the Medication Records Administration (MAR) was conducted, and LPA observed of the records reviewed all are in compliance. CONTINUED ON 809C During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. During visit LPA observed residents relaxing in dining room or common areas eating meals, playing card games and reading newspapers. LPA observed several residents relaxing inside private apartments watching TV and or knitting. LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 10/11/24. The facility had operational smoke and carbon monoxide in bedrooms and common areas. LPA observed documentation from Cosco Fire Protection and Direct Supply Tels. confirming 229 smoke detectors passed on inspection date 10/15/2024. The facility has current liability insurance on file effective 01/01/2024 - 01/01/2025. The facility is current on Community Care Licensing annual dues. A review of five residents (R1-R5) service files and four staff (S1-S4) personnel files revealed to be complete. Facility has a secured location for resident medication and files. No deficiencies during this inspection visit. An exit interview was conducted with Executive Director, and a copy of the report was provided.