Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan.

A current Plan of Operation was reviewed. The facility serves residents 60 years and older, and a Hospice Waiver for thirty (30) resident is approved.

Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 06/01/2026. A surety bond is not applicable. Facility does not handle resident's money.

Physical Plant/Environment Safety:

The building is in a residential neighborhood. The building consists of three floors (ground floor, first floor and second floor). The ground floor/lobby consists of a front desk/reception area, business offices, three (3) activity rooms (tv, game room and activity room), health & wellness office, sales/marketing office, laundry room, beauty salon, storage room, employee break room and garage. The first floor consists of resident rooms, dining room, kitchen, patio area and a storage room. The second floor consists of resident rooms and a storage room. The facility has two (2) operable elevators and were operational during the visit.

(Continued on 809C)

• 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.

All resident rooms located on the first and second floors have a sliding door or a door leading to a balcony. Bedrooms were equipped with a bed, chair, nightstand, adequate lighting, and ample closet/storage space for each resident. Required linen/supplies which include, pillowcase, fitted sheet, blankets, bedspreads and mattress pads were observed. The bathrooms are clean and operational with non-skid mats. The kitchen was observed for the ability to prepare and serve food. Appliances in the kitchen were clean and all appeared functional. The supply of dishes/cups is adequate. During today's visit, LPA observed an appropriate food supply of two (2) days of perishables and seven (7) days of non-perishables. Last fire drill and disaster drills were conducted on 06/19/2025. Drills are conducted every month.

The facility is equipped with a centralized sprinkler system. The facility has a central air and heating system in the common areas of the building and individual AC units inside resident bedrooms. The medications, First-aid kit and resident records are centrally stored and locked in the medication room. First aid kit is fully stocked with a manual. Staff records are centrally stored and locked at the front desk/reception area. Facility does not handle resident P&I monies. The facility smoke detectors are hard wired. Carbon monoxide detectors were observed throughout the facility. The fire extinguishers were fully charged and in compliance. There is a functioning telephone on the premises. The hot water temperature was tested throughout the facility and measured within Title 22 Regulations. Water temperature measure between 107.7 – 112.3 in random rooms that were inspected. All toxins such as cleaning solutions and detergent soap are also locked in the storage room. The grounds of the facility are well landscaped with a ramp that leads to the entrance. A shaded area with chairs is provided in the patio area. The trash cans have covered lids. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises.

Staffing:

There appears to be always sufficient staffing in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency.

Personnel Records/Staff Training: Staff have criminal record clearance, current First-Aid training , medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 10 staff files with no issues observed. Administrator Madeleine Sievert certificate expires on 06/18/2027

Appraisals, TB clearance, Functional Capability Assessment, and emergency information. RCFE complaint poster and Personal rights were observed posted in the facility hallway.

(continued on 809C)

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily.

The facility does have a Resident Council but not active currently.

Food Service:

Sufficient food supply is stored in the kitchen and storage areas consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies.

Incident Medical and Dental:

Ten (10) centrally stored resident medications were reviewed. All medications are administered as order by the physician.

Medical and dental transportation is provided by family, transportation services, or staff.

Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites.

Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies.

No deficiencies observed during the visit. Exit interview was conducted with Administrator Madeleine Sievert and Regional Director Lisa Pham, A copy of the report and appeal rights were issued.