Follow-up·June 9, 2025

On 6/9/2025, Licensing Program Analysts (LPAs) Triel Ellen Lindstrom and Arielle Pascua arrived announced for a case management visit to tour the Memory Care unit. The facility has requested an increase in their capacity from five to fourteen bedridden residents. The Department has received the facility's updated Plan of Operations, which incorporates the required language about dementia care, a signed LIC 200, a completed STD 850, and a new facility sketch that designates bedridden rooms. The LPAs met with Designated Facility Administrator (DFA) Lacy Vincent, who gave them a tour of the new Memory Care unit. On the tour of the Memory Care unit, the LPAs viewed the common areas, two resident bedrooms, two laundry rooms, a storage area, the kitchenette, the reception area, two interior courtyards, and an enclosed outside paved walkway and garden. The current capacity of the unit is 22 residents. The unit is clean and the rooms contain the required furnishings. The LPAs observed residents gathered around a large table with the Activity Director and her assistant doing a painting project. The outdoor area with a walkway is located in the front of the building between it and the parking lot. It is enclosed with a tall metal perimeter fence. The gate leading out of this area is currently unlocked. Because of this, residents are accompanied one-on-one with a caregiver when in this area. A technician has been scheduled to install a delayed egress on the gate in mid-June. The new Memory Care unit contains six rooms that have been cleared for bedridden residents. These six rooms are Rooms # 501, 504, 505, 520, 524, and 525. These rooms are identical to every other room in the unit. The rooms designated as bedridden rooms on the new facility sketch are all located near the corners of hallways. DFA Vincent stated that this location will make it easier for staff to evacuate residents in the case of an emergency, as there is an exit door at each corner. The unit has an approved capacity of forty-two residents. DFA Vincent stated that she recently sent a revised occupancy plan to management, reducing the number of rooms designated for double occupancy from sixteen to eight. This would cap the total occupancy at thirty-six residents maximum. This site visit concludes the Department's approval of the six new bedridden rooms in the facility's Memory Care Unit, increasing the capacity from five to fourteen bedridden residents in the facility. Based on observation and records review made during this site visit, there were no deficiencies observed or cited during today's case management visit. A brief exit interview was conducted with DFA Vincent and a copy of this report was provided to the DFA.