Routine inspection·July 16, 2024

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a 1 year required inspection and met with Administrator Barbara Fleck LPA met with Administrator, Barbara Fleck and the Resident Services Director, Susan Alexander on 07/16/2024 at approximately 1:40 PM. Facility has an approved dementia plan of operation. There is an approved hospice waiver for nine (9) residents. The facility has 156 residents in Assisted Living and Memory Care. All visitors are required to register at the front desk upon entry and residents are supposed to sign out at the front desk when leaving the facility. LPA reviewed five resident files and five employee files and found them to be complete, including updated Needs and Services Plans. All postings were up and visible as required. Toxins are stored in locked cabinets. There was a supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored and locked in the medication room and on the medication carts making them inaccessible to residents and only medication technicians are allowed to handle medications. Facility uses an E-MAR program, utilizing bar codes and computer input for medication administration. There is an active Activities Program, with several engagements taking place each day. LPA will continue Annual Inspection of facility at a later date. No deficiencies were found at the time of inspection. No citations issued.