Routine inspection·April 29, 2025

At 11:30am on 04/29/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the facility annual inspection. LPA met with Administrator, Marjan Albert, announced who he is and the reason for the visit. LPA Jeffries reviewed emergency disaster plan and infection control plan with Administrator. LPA Jeffries conducted a review of the Plan of Operations, with focus on dealing with behavior expressions, dementia and training. LPA Jeffries conducted a cursory review of staff and resident files, including medication audit of Centrally Stored Medication Records (CSMR) and Medication Administration Records (MAR). LPA Jeffries reviewed fire clearance records, and observed a passing fire inspection by Johnson Controls of North American dated 03/20/2025, showing 129 smoke detectors, 9 Carbon Monoxide Detectors, and all components of fire sprinkler detection system throughout the facility as passing. LPA Jeffries noted assorted fire extinguishers throughout the facility primed and in the green and tagged as indicating functioning. LPA Jeffries noted that the campus has a Skilled Nursing Facility approximately in the middle of the facility campus that is currently undergoing construction for a new generator, which will also support a second generator that will serve the CCLD Licensed facility buildings as well. Administrator and LPA conducted a physical tour of the facilities kitchen. LPA Jeffries noted that the facility kitchen is clean and in good repair. LPA noted that there is ample food supply of 2 days of perishable foods and 7 days of non-perishable foods in the facility kitchen. LPA Jeffries noted that the Administration building, Brandel Hall, and the dinning & Services Building were are clean and in good repair, with no exits blocked or obstructed. LPA will need more time to complete physical inspection and will return at a later date to complete entire facility inspection. EXIT INTERVIEW, REPORT READ, and REPORT PROVIDED.