A file review was conducted prior to today’s visit. The facility was last visited on 01/07/2025 for a case management 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 183 non-ambulatory residents of which 8 may bedridden. Approved hospice waivers for 25.

Facility postings at the main entrance included the facility license, Ombudsman contact, confidential complaint contact, Emergency Disaster Plan, personal rights, monthly and daily activity calendar, and the facility sketch with evacuation routes clearly labelled. Sprinkler systems and fire alarms are located throughout the building. Surveillance cameras are located in common areas and exterior areas. Sign in sheets are available for residents and visitors at the reception area. Ramps and handrails at the front were secure. 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 9:10 a.m. LPAs observed the room temperature to be 72 degrees Fahrenheit. The upstairs activity room contained card games, art supplies, reading materials, seating in good condition, and adequate space. At 9:15 a.m. LPA observed two (02) residents engaged in activities. At 9:30 a.m., LPA observed residents gathering for church services in the Theatre Room. The Theatre Room contained reading material, comfortable seating, and a massage chair. Business offices were located near the main entrance. At 10:15 a.m., the house phone was used to call out and deemed operational. At 10:20 a.m., LPA observed fully charged fire extinguishers on the first and second floor hallways which were last inspected on 05/16/24. The southeast and southwest emergency exits were unlocked. Emergency exit paths were unobstructed and free of debris. At approximately 10:30 a.m., LPA observed minor repairs needed to the drywall in the first floor stairwell by the kitchen and on the second floor at the northwest corner. A Technical Violation is issued for the repairs.

The memory care unit is equipped with 15-second delayed egresses at four (04) locations. The activity room in memory care contained art supplies, exercise equipment, and furniture in good repair. Resident bedrooms contained a chair, nightstand, appropriate lighting, storage, and bedding in good condition. At 11:05 a.m. and 11:10 a.m., LPA tested the call systems in Room #115 and Room #118 of the memory care unit. Staff responded to the call within one (01) minute. At 11:15 a.m. LPA measured the water temperature in Room #115 to be 113.7 degrees Fahrenheit. Exit signs were illuminated and displayed exit routes. Fire sprinklers were observed throughout the unit. Three (03) out of three (03) storage rooms were locked. An outdoor area contained shaded patio with furniture in good condition. The medication room near the main entrance was attended and contained a refrigerator and cabinets for medications, medical files, a complete first aid kit, and disposal devices. LPA conducted a medication review at 11:25 a.m. Three (03) out of three (03) resident medications reviewed contained accurate medications counts. Evacuation chairs were observed at the top of each stairway. All public bathrooms contained liquid soap, paper towels, trash cans. At 3:45 p.m., LPA tested the smoke and carbon monoxide detector in Room 107 and determined both to be operational.

LPAs conducted a record review of resident and personnel files at 1:20 p.m. Most employee and resident files were available for audit. However, the licensee did not have a complete file available for audit. Therefore, a deficiency is issued and noted on the corresponding LIC 809-D page.

No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Copy of report provided.