Routine inspection·April 22, 2025

Licensing Program Analysts (LPAs) Jessica Cho and Edward Kim arrived at the facility unannounced for the purpose of conducting the Required 1 Year Annual Inspection. LPAs were greeted and granted entry after explaining the purpose of the visit to Executive Chef Teri McLeod. Executive Director Mandy Taylor arrived approximately 9am to assist with the annual inspection. The facility is licensed to provide services to residents age range 60 and over, (220) non-ambulatory, of which 20 may be bedridden. Non-ambulatory is on the first and second floor and 50% of third floor. Approved for delayed egress, and has a hospice waiver for 40 residents. There are currently 13 residents receiving hospice care services. During the tour with ED Taylor. LPAs inspected all common areas and inspected 16 resident apartment units which had all the required elements. The residents’ personal bathrooms were checked. Toilets and water faucets worked properly, and the grab bars were secure. Showers were free of mold/mildew, and the slip resistant mats were in place. The hot water temperatures in four out of the 16 private bathrooms in the apartments exceeded 120 degrees Fahrenheit measuring at 123.0, 122.0, 126.1, and 121.2. LPAs observed one apartment unit having a strong odor from the litter box. LPAs inspected the kitchen and the dining areas. Facility maintains ample supply of two-day perishables and seven-day non-perishables. LPA observed the emergency food and water in the kitchen and supply storage. The fire extinguishers were mounted, fully charged, and serviced on July 1, 2024. The smoke/carbon monoxide detectors were last tested on November 19, 2024 per the fire alarm inspection report conducted by Tricom Fire & Electric Co. LPAs toured the outside grounds. There were ample seating and shading for the residents, and the walkways were clear of hazards. Facility conducts quarterly disaster drills with the last one conducted on January 30, 2025. LPAs reviewed 15 residents' and 4 staff files. No discrepancies noted. Interviews were conducted with 16 residents and 4 staff. The medications and the Medication Administration Records (MARs) were reviewed. No discrepancies noted. The following were advised: to maintain the hot water temperature between 105-120 degrees Fahrenheit and to remove the source of the odor in the apartment unit of Resident #9 (R9). Based on the observations, a deficiency is being cited on the attached LIC9099-D, and a Technical Violation (TV) is being issued. An exit interview was conducted with Executive Director Mandy Taylor, and a copy of this report including the LIC9099C, LIC9099-D, TV, and the appeal rights were provided at the end of the visit.