Routine inspection·July 23, 2024

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. Interim Administrator Ernest “EJ” Lewis was present at the time of arrival. There were 41 residents in care in the Assisted Living unit with 1 medication technician, 3 caregivers on duty, and 1 activities coordinator on duty. In the “Compass Rose” Memory Care unit, there were 27 residents with 1 medication technician and 3 caregivers on duty. The Compass Rose Lifestyle Assistant Director who currently oversees the activity programming for the Memory Care unit of the facility was also on duty. LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to residents with a dementia diagnosis, and 99 non-ambulatory residents of which 10 may be bedridden. There are 7 residents currently on hospice. Entrance interview conducted: The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. Throughout the facility, there are approximately 18 fire extinguishers and 5 fire pull alarms. The pull alarms alert the local fire department when activated. Fire inspection was most recently conducted on 6/20/2024. There are approximately 81 dual carbon monoxide detectors and smoke alarms throughout the facility. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. LPA observed the dining areas are clean. LPA observed kitchen cabinets, refrigerator, stove, and counters are clean. Assisted Living Residents participate in activities such as special occasion celebrations, music entertainment, Bocce ball, physical therapy, and excursions to local eateries and retail businesses. Memory Care residents participate in activities such as special occasion celebrations, music entertainment, and scenic drives. A "Cycling without Age" activity is available for residents in Assisted Living and Memory Care. Please continue to 809-C, Pg 2. The facility has various sitting areas throughout the first and second floors including a library/reading area, faux fireplace, computer/business center for residents and staff, beauty salon, physical therapy center, and a laundry room. The facility grounds are well maintained with walkways, sitting areas with covered tables and chairs, and raised garden areas. Throughout the interior area and outdoor area, the facility is conducive for socially distanced visitation. Chemicals and cleaning supplies are kept in two locked closets with no access to residents in care. The facility maintains a comfortable temperature. Hallways, bedroom doors, and walls are in good repair. Emergency Disaster plan is posted and all agencies with telephone numbers are listed. Due to time restraints, LPA will return at a later date to continue the inspection. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.