Routine inspection·May 21, 2024

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Annual visit. LPA met with Director of Resident Services, Syril Nelson, and we discussed the purpose of the visit. Executive Director, Stephanie Boudreau is the certified administrator for the facility, and her Administrator's Certificate expires on January 25, 2025. The facility file was reviewed prior to the visit. According to the facility’s license, the facility has a maximum capacity of 783 non-ambulatory elderly residents; age 60 and above. Dementia approved for 23 with delayed egress. The facility is approved for a 25-hospice waiver. The facility was assessed by touring it inside and out. LPA inspected for compliance with safety, maintenance, and operational requirements. LPA interviewed staff, residents in assisted and independent living as well as general conversation with residents in the memory support unit. The facility is separated into three (3) distinct areas, South Tower, North Tower, and the Care Center. LPA briefly interacted with residents in care. All facility staff observed by the LPA have a current criminal record clearance. Nelson stated there are no firearms stored on the premises. The no firearm policy is strictly adhered to. There were five (5) complete dining areas available for all residents. There were at least 2 days of perishable food, and at least 7 days of non-perishable food present, all safely stored in two (2) of the dining areas inspected. Cooking/dining equipment and utensils were present. (continue at LIC809C) (continue from LIC809) There is a facility pool, and LPA toured the area with Nelson. Access to the pool is restricted by way of a key fob and the three (3) doors were secured during the LPA's visit. LPA tested one of the exit doors equipped with a delayed egress door and confirmed working properly. There were a total of four (4) delayed egress exit doors. There were a total of 11 fire extinguishers inspected that had been serviced in February 2024. Today's inspection consisted of parts of South Tower, Assisted Living, and the Care Center. The hot water temperature was measured by maintenance once a month. LPA observed smoke alarms were present in each room. The appliances in the resident rooms were in working order. Each room observed was clean, sanitary, and in good operating condition. It was also observed pull cords in each of the residents' rooms. All bathrooms inspected had grab bars installed by the toilets and shower areas. Cleaning supplies for the housekeeping staff were secured in the housekeeping closet. The signal system was tested in the presence of Nelson; staff responded in less than one (5) minutes. Some of the residents also utilize a pendant that can be worn to request staff assistance in emergencies. The pendant was also tested in the presence of Nelson, and staff responded in less than one (1) minute. Medications were labeled, as required and stored in locked areas. LPA observed several medication carts that were locked and secured. In independent living, all residents keep their medication locked in a medication cabinet. Keys to the medication cabinets were kept and controlled by appropriate staff with responsibility for medication management. All required postings were observed in the facility in assisted living. LPA interviewed staff and reviewed multiple staff and resident records/files. LPA interviews did not raise any licensing concerns. The files that LPA reviewed contained the required documents. Confidential records were stored in locked areas. Facility staff conducted an emergency drill on May 20, 2024, LPA verified that emergency drills were conducted at least quarterly in some cases every two (2) months. Fire drills were conducted each month. The facility updated its disaster and emergency preparedness plan on May 10, 2024. Liability insurance was current, expiration date 12/31/2024. No violations were observed during the visit. During the visit, an exit interview was conducted with the Director of Resident Services, Syril Nelson, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.