Routine inspection·April 23, 2024

Licensing Program Analysts (LPAs) Joseph Alejandre, Faith La, Michael Tea and Rose Ruppert made an unannounced visit to conduct the required annual inspection. LPAs met with Executive Director (ED) Brian Keys and explained the reason for the visit. Facility consists of two buildings in which one is for Assisted Living (AL) and the other for Memory Care (MC). The capacity is 195 non-ambulatory of which ten can be bedridden and a hospice waiver for eight. Brian Keys' Administrator's Certificate expires on February 18, 2025. LPAs observed the PUB 475 poster (See Something, Say Something Poster) posted next to the mailboxes and not in the main entrance of the facility. The PUB 475 poster posted is 20" X 26." LPAs and ED Keys toured the facility. LPAs observed the kitchen is clean and organized. There is a two day supply of perishable food and a seven day supply of non-perishable food on-hand in the kitchen. LPAs observed that the refrigerator and the freezer had a temperature log posted in the kitchen. LPAs and ED toured resident rooms on the first and second floors in AL. LPAs and ED toured the resident rooms in the MC building. LPAs inspected ten resident rooms. All resident rooms had the required furnishings. All resident bathrooms were clean and operational. The hot water in the ten resident rooms inspected measured 111.5 degrees Fahrenheit to 119.3 degrees Fahrenheit. LPAs observed residents participating in yoga in the yoga room. There is a fitness room and activity room for AL residents. There is a movie theater, music room and activity room from MC residents in the MC building. There is an outdoor courtyard in both buildings for residents to sit outside. There are fire extinguishers on every floor and all fire extinguishers are fully charged. LPAs observed emergency evacuation chairs in each stairwell. The last emergency fire drill was conducted on March 29, 2024. The delayed egress tested operational in the MC Building. The fire alarm and life safety system was inspected and tested operational on July 7, 2023. LPAs observed medications are kept secured in a medication cart that is locked in a medication room. LPAs observed that the First Aid Kit did not contain a current edition First Aid Manual but had a pocket First Aid booklet. LPAs interviewed staff and residents. LPAs reviewed ten staff files with no discrepancies observed. All staff files reviewed had current CPR/First Aid training. All direct care staff files reviewed met training requirements. LPAs reviewed twelve resident files with no discrepancies observed. LPAs inspected medication and medication administration records (MAR) for six residents. No discrepancies observed. All resident files had the required documents. No obstacles or hazards were noted inside or outside of the facility. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.