Routine inspection·May 26, 2021

On 5/26/21, 9:00 AM, Licensing Program Analysts (LPAs) Toan Luong and Mark Jeffries initiated facility risk assessment questionnaire. LPAs conducted an unannounced onsite one year infectious control annual visit to the facility. LPAs met with Administrator Chris Parker and explained the purpose of the visit. Administrator took LPAs on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department. The facility is a Continuing Care Retirement Community that has a campus consisting of 26 buildings. Buildings 1-14 are designated for Independent Living. Building 15 is designated for Assisted Living and Memory Care. Building 16 is a skilled nursing facility. Building 17 is the Maintenance Shop. LPAs recommended a sign should be posted to limit area to staff only. Building 18 is the Administration Building. Building 19 is the generator area. Building 20 is designated for Assisted Living on the second floor, and the first floor is the pool and other amenities. LPAs advised door leading to pool patio should self latch. Buildings 21-24 are Independent Living. Building 26 is a utilities building. Building 15 is Memory Care, delayed regress, is functioning properly. Medication Room was reviewed by LPAs. Facility uses program Point Click Care for Medication Administration Records. Facility has activities calendars for Memory Care and Assisted Living. In building 15, LPAs recommended locking closet doors and other doors not in use. During the facility tour, LPAs observed mitigation control signage throughout the facility. LPAs recommended posting a sign at the northeast entrance (top of parking lot) of the Administration Building to clarify single check-in point. LPAs discussed with Administrator isolation, quarantine, positive residents, and cohorting under mitigation control. LPAs reviewed the Annual Mitigation Inspection Control Tool Module. Module was addressed with Administrator to satisfaction. Exit interview was conducted. No deficiencies were cited. Report emailed to Administrator.