Routine inspection·August 28, 2024

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. LPA was greeted by Front Desk Receptionist Staff 1 (S1). Administrator Alejandra Nunez was present during the inspection. At the time of arrival, there were 59 residents in care with four (4) medication technicians/caregivers on duty along with three (3) caregivers, one (1) Clinical Director, two (2) activities coordinators, one (1) activity director, and the Administrator on duty. LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to forty (40) non-ambulatory residents with a Dementia diagnosis, a Hospice Waiver for twenty-five (25) residents, and is approved for delayed egress. Currently, there are twelve (12) residents on hospice. Entrance interview conducted: A tour of the physical environment and accommodations were assessed. The following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the two-story facility for fire safety, personal accommodations, and food service. The facility maintains a comfortable room temperature. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. There are approximately sixteen (16) fire extinguishers on the premises serviced once each month since 10/6/2023. There are approximately eight (8) fire pull alarms throughout the facility. There are approximately seventy-eight (78) dual carbon monoxide detectors/smoke alarms throughout the facility. The local fire department is alerted when/if the smoke alarms/carbon monoxide detectors are activated. Fire drills are conducted approximately twice each year. Please continue to 809-C, Pg 2. Residents participate at will in activities such as music and live entertainment, spiritual and religious activities, outings with family members, games, art activities, painting activities, storytelling, word games, travel shows, tri-shaw rides, van rides, and picnics to local parks and attractions. Additionally, the facility participates in the state-based Vitality program through the local community college. Activities are scheduled in the mornings, afternoons, and evenings. Evening activities such as games and storytelling have been incorporated for all residents especially those who may experience sundowning behaviors. Most recently, the facility incorporated the “Freedom Nature Trax” which is a ‘skid steer’ mobility device that the individual’s wheelchair attaches to giving them the mobility to access trails, parks, beaches, and other outdoor paths with full and/or partial independence. Snacks and beverages are available for residents in care upon request. LPA observed the kitchen area and dining areas to be clean. Cleaning agents and the toxic chemicals are kept in locked supply rooms throughout the facility. The facility consists of four neighborhoods each conducive to the level of care required for the residents. All bedrooms have sufficient lighting, nightstands, beds, and bed furnishings. A locked medication cart is designated for each neighborhood in the Wellness Clinic. First aid supplies are also kept in the Wellness Clinic. Neighborhood #4 is a neighborhood for residents who require a higher level of care. The facility maintains a higher staff ratio in Neighborhood #4 to meet the needs of the residents. Throughout the neighborhoods, there are dining rooms, libraries, beauty salon, social seating areas, outdoor patios, and paved walkways conducive for leisure walks throughout the facility. The physical environment was checked for cleanliness and condition. The facility was seen to be in good repair inside and outside. First aid kit and additional first aid supplies are kept in a locked centrally stored cabinet in the Wellness Clinic, the Personal Care area, and in the kitchen. LPA reviewed Staff records for trainings, health screenings, and background checks. All staff records are up-to-date and trainings are current. LPA reviewed Residents' records for medication administration and medication record keeping. All residents’ records are complete. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.