The facility consisted of one building with six (6) levels and assisted living units on floors 1 to 5. The ED informed the LPA that the facility had 49 residents in care at the time.

At 9:20 AM, LPA initiated a walk-through of the facility, accompanied by ED.

LPA inspected randomly selected five (5) resident apartments. The apartments 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 108.4°F and 112.6°F. The apartments also contained private kitchen, washer, and dryer units.

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. A four week dining menu and an alternate menu was available to residents.

LPA inspected the fire extinguishers mounted on the hallway walls and found them fully charged, with the last service tag dated January 08, 2025.

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 observed and inspected a locked centrally stored medication cart in the wellness center. Medications were organized separately for each resident. Narcotics were locked. All medication bottles and bubble packs were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete.

LPA inspected activity areas, library, media room, fitness center, outdoor garden, and other commons areas. Activity calendar was posted one month is advance for the residents. All common areas were free from obstructions, and hallways were well-lit.

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 inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted quarterly, with the most recent drill completed on 05/14/2025.

The HR director was out on unplanned bereavement leave and employee files inside the cabinet were locked. The keys were not available to access these staff files. ED stated they are going to have another set of keys available. The annual inspection will need to be continued at a later time.

No deficiencies were cited during today's visit.

An exit interview was conducted with the Executive Director. A copy of this report was provided to the Executive Director, Tim Selleck, whose signature on this form confirms receipt of the report.