Routine inspection·August 22, 2024

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct the annual inspection. LPA met with Administrator Michael Clymo upon arrival. Currently there are 74 residents of which 2 residents are receiving hospice care. LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 8 resident rooms, medication room, staff area, bathrooms, kitchen, common living spaces, outdoor spaces, and activity areas. In the areas toured no immediate health, safety, or personal rights violations were observed. Hot water was measured at 110 degrees. LPA toured the assisted living side of the facility and the memory care unit with a delayed egress. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete. LPA reviewed 10 resident files and 10 staff files. LPA reviewed 3 resident medications comparing with current physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. LPA observed a copy of current liability insurance. Deficiencies are being cited on the 809-D. Exit interview conducted and copy of report provided.