A file review was conducted prior to the visit.

The facility was last visited on 12/05/25 for a complaint visit. It is a three-story building with separated areas for assisted living residents and memory care residents. The areas are separated by fifteen (15) second delayed egress doors, activated by numeric keypads. In total, the facility has one hundred eight (108) bedrooms in assisted living, nineteen (19) bedrooms in memory care, private and shared bathrooms, dining areas, recreation spaces, and indoor and outdoor common areas. Its most recent fire clearance was approved on 12/18/25 for a capacity increase from one hundred thirty-eight (138) residents to one hundred sixty (160) residents, of which one hundred twenty-seven (127) may be non-ambulatory, twenty three (23) may be bedridden, and ten (10) may be ambulatory only. The facility serves residents with dementia. Approved hospice waivers for twenty-five (25).

LPA and staff toured the facility inside and out at 11:00 a.m. The main entrance has automatic sliding doors and manual doors for entry. The walkway is covered, maintained, and free of hazards. A designated smoking area is present near the main entrance. Sanitizer and masks are available at the front. Sign-in sheets for guests, residents, and outside agencies were posted. The main lobby contained furniture in good repair, art supplies, music, televisions, and activities. LPA observed a Zumba class with approximately 20 residents at 11:00 a.m. and Bingo at 2:00 p.m. A bistro and beauty salon were located at the southern edge of the lobby area.

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

LPA conducted a medication review in the assisted living and memory care medication rooms at 11:30 a.m. LPA reviewed and staff counted quantities of five (05) residents’ medications and controlled narcotics. All medications were accounted for and matched the digital and paper records. The medication room was locked from the outside. Medications were further locked in medication carts within the room.

Between 12:00 p.m. and 1:00 p.m. LPA and staff inspected rooms #108, #257, #227, and Memory Care #9. LPA tested the water temperatures to be 111.2 degrees, 112.1 degrees, 108.7 degrees, and 107.4 degrees Fahrenheit. The call systems in all four (04) rooms were tested. Staff arrived within five (05) minutes of each test. Smoke and carbon monoxide alarms were also tested and operational. All bedrooms contained a chair, lamp, nightstand, storage, and beds with adequate bedding. All furnishings were clean and in good condition. Bedrooms were accessed by key cards. Bathrooms and showers contained grab bars, non-skid surfaces, liquid soap, paper towels, and trash cans.

A locked laundry area upstairs contained four operable (04) washing machines and four (04) dryers. All machines were in use and attended by staff. Detergent was stored in a locked storage area near the laundry area. A sign was posted showing resident laundry days and hours.

The facility has three (03) elevators. All were in working condition today. Third floor access was available through the northern elevator which required a key. It was permitted as of 08/21/25. The third floor was under construction and inaccessible to residents. It contained a cable room, CCTV room, office spaces, emergency water supply, and a future laundry room. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. At 1:45 p.m., the walk-in refrigerator and freezer temperatures were recorded at 39 and -2 degrees Fahrenheit, respectively. Appliances were in good condition. Surfaces were sanitary. The food preparation area was free of chemicals and insects. Dietary cards, food handling certificates, and daily and weekly menus were posted. The activity room contained a television and theater-style seating, board games, puzzles, and sporting equipment.

All emergency exit paths were free from obstructions. Exit doors and gates were unlocked. Emergency evacuation chairs were observed at the top of each stairwell.

LPA reviewed resident and staff files between 9:30 a.m. and 3:00 p.m. All files were complete and available for audit. LPA also reviewed Reg 4 testing from the fire department. All systems passed on 10/13/25 and 12/09/25.

During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed.

Exit interview conducted. Copy of report provided.