Routine inspection·September 18, 2024

Licensing Program Analysts (LPA) Graham Gunby and Kevin Mknelly arrived unannounced at the facility to conduct a required annual inspection utilizing the full CARE tool. LPA met with Executive Director, Carol Pickard, and explained the purpose of the visit. Today's census is 114 residents, the facility is licensed for 199 residents with a hospice waiver for 15. During today's inspection, LPAs and Executive Director conducted a tour the interior and exterior of the facility. Areas toured included but not limited to: courtyard, memory care unit bedrooms, assisted living unit bedrooms, main dining, kitchen, gym, and the common areas. LPAs observed care staff assisting residents with walking and other activities. LPAs observed the facility to be clean, safe and in good repair. File review was conducted for 10 residents and 6 personnel files. LPAs observed the files to be mostly complete with the required documents. Inspection tool completed and found facility to be in substantial compliance. LPAs noted and discussed with the administrator the requirements for the hospice care plan content. During the personnel file reviews LPAs requested copies of 2 staff first aid training certificates. No deficiencies observed during today's inspection. Exit interview conducted and a copy of report was provided.