The following were observed/inspected:

Operational Requirements: A hospice waiver for five (5) residents has been approved. A fire clearance for 100 non-ambulatory residents; of which 10 may be bedridden is in place. Facility handles resident monies and has set up trust accounts. The Surety Bond is current. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 11/1/2024.

Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. On 4/20/2024, Fire Drill Service conducted an inspection. No violations were noted at the time of the inspection. The facility has fully charged fire extinguishers. The signal system was tested and is operational. Water temperature readings did not measured within the required 105 - 120 degrees Fahrenheit. A total 10 out 17 rooms inspected had water temperatures ranging from 83.8 DF - 125.0 Degrees Fahrenheit.

*On 4/23/2024, a technical advisory was issued because the signal system wall pull-string in resident rooms is inaccessible to residents that are non-ambulatory.

• The facility has a Memory Care Unit located in the 1st floor. Facility is a 3-story building consisting of 66 resident rooms, 2 activity rooms, beauty salon, room, 2 dining rooms, laundry room, and a courtyard patio area in the Memory Care Unit. There are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. Beds had required bedding, linens, and mattress pads.
• On 4/20/2024, Fire Drill Service conducted an inspection. No violations were noted at the time of the inspection. The facility has fully charged fire extinguishers. The signal system was tested and is operational. However, a technical advisory was issued because the signal system in the resident rooms is inaccessible to residents that are non-ambulatory.
• The stairwell evacuation chairs are not kept in the stairwells. They were observed in the hallway. A technical violation was issued.
• Water temperature readings did not measured within the required 105 - 120 degrees Fahrenheit. A total 10 out 17 rooms inspected had water temperatures ranging from 83.8 DF - 125.0 Degrees Fahrenheit. Citation was issued.

• A total of 45 staff members provide care and supervision to the clients. Fifteen (15) registry staff are still being used when there are staffing shortages.

• Administrator certificate expired. Administrator provided proof that recertification training documents were submitted to CCL Recertification unit on March 20, 2023. Recertification process is pending.
• Staff have criminal background clearance and training.
• Nine (9) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training was observed.

• A total of eight (8) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, Individual Service Plans, and medication records.
• RCFE complaint poster and Personal rights were observed posted.

• Sufficient space to accommodate both indoor and outdoor activities was observed.
• An activity calendar is posted in the 2st floor hallway. The facility has a Resident Council.

• Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
• 18 residents are on modified diets. Physician orders are on file and special diet lists are kept in the kitchen area.
• On 4/23/2024, LPA observed the large freezers are not operating. Per Dietary Supervisor, licensee was notified of non-operable freezers in January 2024. The freezers were ordered on May 20, 2024.

• Eight (8) centrally stored resident medications were reviewed. containing a 30-day supply of medications.
• Medical and dental transportation is provided. Facility has one (1) van for resident transport.

• Emergency and Disaster Plan LIC 610E was reviewed. There are no evacuation chairs in each stairway; one (1) stairway has an inoperable stair lift. A citation was issued.
• Facility has a First Aid Kit and Manual. Records of resident Appraisal and Needs services plans are part of Emergency training.

• Two (2) residents are receiving hospice services and four (4) residents receive home health services.
• Postural support physician orders are on file. Half bed rails for mobility assistance were observed in some resident rooms. No residents have prohibited health conditions.
• Individual Service Plans and Appraisals are on file.