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25 | Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Executive Director Bryan Hadley and explained the reason for the visit. Bryan Hadley's Administrator's certificate expires on February 3, 2025. Facility is approved for delayed egress exits in the memory care unit. Facility is a two story building with 114 resident rooms which includes a memory care unit. LPA and the Executive Director (ED) toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the hallway next to the main entrance. LPA and the ED toured the kitchen and dining room. LPA observed the kitchen is clean and organized. There is a two day supply of perishable food and a seven day supply of non-perishable food on-hand in the kitchen. LPA observed that the refrigerators and the freezers had temperature logs posted on them. The refrigerators and freezers were at the required temperatures. LPA and ED toured 10 resident rooms on the first and second floors. All resident rooms had the required furnishings and bed linens. All resident bathrooms were clean and operational. The hot water in the resident rooms inspected measured 106.7 degrees Fahrenheit to 111.5 degrees Fahrenheit. There is a library next to the dining room with games and puzzles and a TV room for residents. There are fire extinguishers on each floor and all fire extinguishers are fully charged. The facility has 4 stairwells. LPA observed an emergency evacuation chair at the top of each stairwell. The last emergency disaster drill was conducted on June 12, 2024. LPA and ED toured the memory care unit. LPA observed the resident rooms in memory care had the required furnishings and bed linens. There is an outdoor patio in memory care with shaded seating for residents to sit outside. The delayed egress exits in memory care tested operational. The fire alarm/fire detection system was inspected and tested operational on June 6, 2024. LPA observed medications are kept secured in a medication cart that is locked in the medication room. LPA interviewed staff and residents. LPA reviewed 5 staff files with no discrepancies observed. All staff files reviewed had the required annual training. LPA reviewed 10 resident files, no discrepancies observed. LPA inspected resident medications. LPA observed that Resident 1 was missing 2 of their 12 prescribed medications. No other discrepancies observed. No obstacles or hazards were noted inside or outside of the facility. |