At approximately 10:00am, Administrator and LPA conducted a full facility walk through and tour. This is a two story facility with a section dedicated to memory care on the first floor. The facility is square in shape with an outdoor courtyard in the center and one wing off to the south-east. LPA noted upon entering the main entry a lobby with reception desk to the left; an entrance to the large communal dining room across from the main entry doors; and a resident snack bar, the main kitchen, staff laundry room, staff room, maintenance room and employee entrance are to the right. The communal dining room has a smaller banquet room for small private events. On the first floor past the reception desk are administrative offices, a gathering/activity space (with piano, fishtank, and self-contained fireplace for residents and visitors to enjoy), 32 resident rooms with en-suite bathrooms, medication room, a dedicated activity room, public restrooms, laundry room and maintenance/housekeeping closets locked for resident safety. The memory care unit is separated by coded egress doors with an additional 15 resident rooms that have en-suite bathrooms, multiple activity rooms, a dining room and a fenced outdoor area with tables and shade for residents and visitors. LPA noted meals are delivered from the main kitchen to the memory care unit and served from the memory care kitchen. On the second floor there are 49 resident rooms with en-suite bathrooms, physical therapy room, laundry room, snack bar area with seating, beauty shop, and a TV/activity space. LPA inspected a sample number of resident rooms and noted that the rooms had working lights, ample storage, working appliances and non-skid surfaces in the showers. LPA noted an emergency evacuation chair located at the top of the five stairwells and the elevator was serviced on 12/24/2024.

(Continued on LIC809-C)

• 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.

The facility has wired/battery operated dual smoke/carbon monoxide detectors in each resident room and smoke detectors in the hallways tested by Alpha Fire on 8/6/2025. LPA observed fire extinguishers throughout the facility tagged current and in the green compression range, being serviced during todays visit. LPA tested facility hot water at various locations measuring between 109 & 112*(f), within regulation temperatures 105*-120* (f). LPA noted that the facility has no obstructions in hallways, doorways or exits. Medications are locked in medication carts. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication and Destruction Records.

Administrator and LPA conducted a partial review of the facility annual CARE tools module. LPA will need to return to finish the annual. At this time no deficiencies are being cited.

Exit interview, report read, and report provided to the Administrator.