LPAs and Administrator toured the facility inside and out at 9:30 a.m.

A file review was conducted prior to the visit.

Today’s inspection was conducted due to a Change of Owner ship with residents in care. The facility was last visited on 11/29/2023 for an annual visit. It is a two-story building with assisted living and memory care units, shared and private rooms, common areas, offices, beauty salon, theatre room, medication room, and outdoor areas. It has an approved fire clearance for 175 non-ambulatory residents and 8 may bedridden residents.

Facility postings included the facility license, Ombudsman contact, confidential complaint contact, Emergency Disaster Plan, theft policy, personal rights, activity calendar, facility sketch with evacuation routes clearly labelled, and a blank copy of an admission agreement. Sprinkler systems and fire alarms were located throughout the building. Surveillance cameras are located in common areas and exterior areas.

Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. Linen closets with adequate supplies of fresh linens were located on both floors. At 9:20 a.m. LPAs observed the room temperature to be 78.5 degrees Fahrenheit.

The courtyard contained a gas grill, patio furniture in good condition, walkways free of obstructions, a designated smoking area, a backup generator, and unlocked exit gates. Two locked sheds contained maintenance supplies and extra bedroom supplies.

The laundry area contained two industrial washers and dryers. At 10:10 a.m. LPAs observed one (01) of the two (02) washers to be out of order. The administrator confirmed a work order was submitted to fix the washer. Detergents were made inaccessible in an adjacent storage room.

The dining room contained adequate seating. Daily menus and alternative menus were posted at each table. The kitchen area contained appropriate equipment and sanitary surfaces. Resident specialized diets were posted on the wall along with temperature logs. The pantry, refrigerator and freezer contained adequate supplies of perishable, non-perishable, and emergency foods. A hot box was used to transport memory care resident meals and maintain at safe temperatures. At 10:15 a.m. LPAs measured the walk-in refrigerator and freezer temperatures to be 30 degrees and -25 degrees Fahrenheit, respectively. A first aid kit was observed in the kitchen manger’s office.

LPAs toured Room #186, #108, and #205, and #254 in the assisted living unit. Resident rooms contained appropriate furnishings which were in good repair. At 10:35 a.m. LPAs tested the house telephone to be operational. The locked medication room near the main entrance contained a refrigerator and cabinets for medications, medical files, and disposal devices. LPAs conducted a medication review at 11:15 a.m.

Evacuation chairs were observed at the top of each stairway. At 11:37 a.m. LPAs tested the dual functioning smoke and carbon monoxide detectors to be functional.

LPAs and the administrator reviewed Component III at approximately 1:00 p.m.

LPAs conducted a record review of resident and personnel files at 1:30 p.m.

At 2:40 p.m. LPAs and Administrator discussed plans for future facility renovations. The Administrator agreed to notify the Department and obtain all necessary permits prior to any construction.

During today's inspection, the facility was in compliance with Title 22 regulations. Prelicensing is complete and the facility has no deficiencies.

Exit interview conducted. Copy of report provided.