Routine inspection·June 24, 2026

Licensing Program Analyst, LPA, Noel Wolf Petersen and Licensing Program Manager, LPM Liza King arrived unannounced to conduct a annual inspection of the facility. The LPA and LPM met with the Executive Director Jackie Hernandez to explain the purpose of the visit. A physical inspection was completed, including but not limited to the bedrooms/bathrooms, the kitchen, the exterior and emergency route gate, the memory care unit, the common areas, and storage areas. Traffic areas are unobstructed and well lit. The fire extinguishers are dated may 6 2026, and the first aid kit has all necessary components. there are some ongoing repairs of the air conditioning, (a condenser tray leaking), the Maintenance director provided that the facility was probably going to replace the unit. at the time of the annual inspection, the air temperature within the facility is in range 68-85, and the LPA gave guidance that temperature should be maintained for the residents through the repair/replacement of the unit. Bedrooms * bathrooms: One of 6 observed bedrooms was malodorus for R1. LPA gave guidance that increased housekeeping checks should be included with the care plans for those residents with with inconteince issues. 5 of 5 resident rooms checked have functional bathroom hardware(sink facuets, showers, toilets). Water delivered at the sink measured between 110 and 115. 6 of 6 Bedrooms are furnished with required furniture, bathrooms have secure grab bars. Kitchen: Perishable/nonperishable food storage is at a capacity for 2/7 days for 65 residents plus 3 snacks per day, the sharps and toxics are stored seperately from each other and secure from the residents. Food for the residents is able to be held within the walk in, and a snack bar is maintained for resident access between meals. 4 residents have a concern about increasing menu options, specifically the availability of vegetables. The facility had a recent resident council and a meal suggestion survey where the issue was raised, and the LPA gave guidance that grievance procedure process should play out from here. Continued on c page 1 meal service was observed, turkey, mashed potatoes, gravy, cranberries, a jello/icecream. Senior Kitchen staff in interview outlined a desire to be more responsive to resident menu requests by adding additional vendors, adding a deep fryer, and adding a salad bar. There was a recent issue, a lack of spoons which was impacting service to the residents. New spoons have been ordered. 1 med pass was observed. Medtechs were observed to be handing out medications to the approprite parties in a timely fashion. No concerns with the medpass as observed. Recent medication MARs were checked for 11 residents, 1 had a discrepancy resolved as part of a complaint earlier in the month, and the other 10 were error free. There is a outstanding discrepancy on a the controlled substances log, which the facility resolved internally to the satisfaction of the department at this time. Exterior is clean, there is a water feature back by memory care the LPA gave guidance should have rocks added to make the basins shallow enough as to mitgate any risk of drowning. E vacuation routes all exit out the front of the facility which is ungated. Memory care doors unlock in the event of a fire. LPM reviewed 10 client files. Resident files were reviewed for the health training, admission agreements, recent medical assessments, and recent significant events. One resident deteriorated rapidly after a fall, internal investigation? LPM reviewed 10 staff files. 2/10 staff did not have current first aide training. A discussion occurred with the Administrator who verified that training is scheduled to be completed by 06/26/2026. 3/10 staff files reviewed showed there were past due annual trainings to be completed. According to the Administra tor these staff have been counseled and will have the trainings completed by 06/26/2026. It appears that the facility needs to put systems in place to better hold staff accountable for upcoming and past due trainings. The facility currently uses relias which runs reports to show trainings that are coming/due and past due. Guidance was provided as well that although some trainings are only required upon initial hire, there are subjects which would be a best practice to revisit on occassion. Additionally, the facilities current practice is to use resumes in place of an application which provides a work history and is an acceptable alternative. Continued on c page Common areas: Common areas were observed to have adequate space for activites. in interview with the activities director and assistant activities director, they make observations about the accesibility and preferance of the clients for the scheduled activities. todays activities are morning walk, carnival, yoga, bingo, and card game(corner kings). the memory care has mostly the same activites minus the carnival. Memory care: is clean, traffic areas are well lit, 4 of 4 bedrooms have required furnishing and furniture, 4 of 4 bathrooms have functional hardware. water temperature delivered at the sink are measured between 108 and 112. Administrator files were reviewed including the administrators certificate, facility license, required postings (ombudaman poster, client rights poster, federal workers rights poster, activity calenders, menu calender), Liability insurance, workers comp insurance. No citations issued as part of this visit, a copy of the report was read and given to the administrator. Exit interview conducted. The Annual needs futher investigation to review service notes, emergency plan, fire drill log, pull cord log, resident council meeting notes, and infection control plan.