The facility consisted of one building with two floors for Assisted Living and Independent Living units. The DON informed the LPA that the facility had 67 residents in care at the time, including 22 in Assisted Living and 45 in Independent Living.

LPA initiated a walk-through of the facility, accompanied by DON.

LPA inspected randomly selected seven (7) resident rooms in Assisted Living. The rooms were found to be clean, well-lit, and equipped with the required furniture. LPA inspected the private bathrooms in random rooms. The bathrooms contained soap, grab bars, towels, a trash can, and non-slip flooring. The hot water temperature at the sink faucets measured between 114.7°F and 115.3°F. “No Smoking / Oxygen in Use” signs were observed posted outside the residents’ room where oxygen was administered.

LPA inspected the main kitchen and found it clean. The refrigerator, freezer, and pantry cabinets were checked, and there was a sufficient supply of fresh perishable food for two (2) days and nonperishable staples for seven (7) days. No expired food items were found. Open food items were wrapped and dated. The dining room was inspected and was found to be clean, with all furniture in good repair.

LPA inspected the fire extinguishers mounted on the hallway and kitchen walls and found them fully charged, with the last service tag dated 4/25/2025. LPA reviewed the Annual Fire Alarm service/test report, conducted on 03/05/2025 by Siemens Industry Inc.

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.

LPA inspected activity areas, parlor, library, lounges, and other commons areas and observed residents actively engaged in recreational programs and activities. All common areas were free from obstructions, and hallways were well-lit. Sharp objects, detergents, and chemicals were observed to be locked and inaccessible to persons in care.

LPA toured the outside courtyard and patio areas and found passageways in good condition, free of obstructions, and without any blocking or tripping hazards. These areas had patio tables, chairs, and umbrellas for residents’ use. No accessible bodies of water or hazards were observed.

LPA observed a locked centrally stored medication room on the first floor. Medications were organized separately for each resident in a medication cabinet. Narcotics were locked. All medication bottles and bubble packs were properly labeled. At 11:10 AM, Centrally Stored Medication Records were reviewed, and a medication count check was performed. LPA observed that the medication counts for one (1) medication ‘Melatonin 5 MG tablet’ bubble pack for one (1) resident (R1) was found to be inaccurate. 30 tablets, a 30 day’s supply of this medication were logged in centrally stored medication record with a start date of 06/27/2025. The start date on the bubble pack was marked as 06/27/2025 as well. The dosage of this medication was to take 1 tablet daily at bedtime. 1 tablet was observed intact in the bubble pack. Medication Administration Record indicated R1 refused medication on 07/08/2025. Today is 12:30 PM on 07/29/2025, the medication for 31 days should have been administered to R1, but only 29 days of medication bubbles were popped up. Two (2) less days of medication were administered to R1. LPA also reviewed Centrally Stored Records and Medication Administration Record and conducted medication count for ‘Citrucel 500 MG Caplet’. Two (2) less days of this medication were also administered to R1.

LPA reviewed six (6) staff personnel records and five (5) resident records. The LPA observed that 5 of 5 residents had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, Consent forms, Safeguard personal property and valuables, and Personal rights forms. 3 of 5 residents (R1, R4, and R5) didn’t receive Medical Assessment in the last 12 months. LPA observed that 6 of 6 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 6 of 6 staff members were associated with the facility.

Continued on LIC809-C

The following updated forms are requested to be submitted to CCLD by 08/05/2025:

• LIC 500: Personnel Report
• LIC 308: Designation of Facility Responsibility
• Certificate of Liability Insurance
• Administrator Certificate(s)

An exit interview was conducted, and Plans of Correction were reviewed and developed with the DON. A copy of this report and appeal rights were discussed and provided to the DON, Ann Kaye, whose signature on this form confirms receipt of these documents.