Routine inspection (multi-day)·February 20, 2024

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers were granted entry into the facility by Executive Director Angela Scott-Kapiloff after identifying herself and stating the purpose of the inspection. The facility serves elderly residents, age 60 and above, 101 whom may be non-ambulatory. There is an approved Hospice Waiver for 18 residents. The facility is approved for delayed egress. LPA was accompanied by Scott-Kapiloff for a tour of the facility which was conducted inside and out and included a sample of resident units, the dining area and recreation rooms. There is a fire signal system in place and the carbon monoxide detectors were operational. The last disaster drill was conducted on December 2023. Exterior and interior passageways were free from obstructions. Pull cords, sensor alerts with pendants are present in the facility. LPA observed functionality of signal system. Resident and facility room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. [Continued on 809-C] [Continued from 809] Facility has a two-day supply of perishable and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closet. Medication room is located on the first floor and second floor. The medication carts were locked and stored in the medication rooms. Medications were labeled and kept in compliance with label instructions. LPA interview confirmed the licensee provides assistance in meeting medical and dental needs. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA also conducted a review of In-service training procedures. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. There is a designated movie room, designated art/craft room and a garden activity patio along with gathering areas throughout the facility. At the time of visit, LPA observed a large group activity taking place on both the main floor and memory care unit. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No deficiencies were sited at the time of visit. A final exit interview and a copy of this report, Licensee/Appeal Rights - LIC 9058 (rev. 01/16), were provided to , Executive Director Scott Kapiloff whose signature on this form acknowledges receipt of these documents.