Facility Records: LPA reviewed the quarterly inspections, testing and maintenance reports for the wet pipe and fire sprinkler system conducted on 01/15/2025, 05/05/2025, and 07/16/2025 indicating a pass in all areas. The annual fire alarm system inspection report conducted on 07/16/2025 where all three- hundred -thirty-seven (337) smoke alarms, carbon monoxide detectors/ devices including but not limited to auxiliary, control, indicating, initiating, supervisory devices were tested, functioned properly, serviced and passed. The last twenty-four (24) hours of the alert system and pendant activity used by residents to alert staff for assistance was reviewed. The facility’s alert system includes a call button installed in every restroom and a pendant-style device worn as a necklace by residents. Both systems are integrated and designed to generate alerts that immediately notify staff when assistance is needed. The review revealed that, based on forty-four (44) recorded alerts, staff responded within one (1) to thirty- seven (37) minutes. LPA reviewed facility notes related to times that were longer than fifteen (15) minutes. The daily vehicle inspections, and annual Inspection report that was conducted on 03/05/2025 was reviewed for all facility vehicles. All records were in order.

Infection Control / Emergency disaster planning: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The last emergency disaster drill took place on 09/4/2025 and conducted monthly covering all shifts and areas of emergency disasters. LPA reviewed the fire drill report conducted on 08/15/2025 at 10:45 p.m. in the memory care unit of a simulated fire in a resident room and a disaster drill on 08/15/2025 at 11 p.m. of a simulated extreme weather flooding both indicating a pass. The last in service training on infection control was conducted on 09/24/2025. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard.

Interviews: Starting at 1:26 p.m nine (9) staff interviews were conducted which indicated that staff are knowledgeable in resident rights, the various forms of abuse, and appropriate reporting procedures. Starting at 3:00 p.m. LPA conducted three (3) group interviews of eleven (11) residents total during the facilities OctoberFest festival. Group one (1) consisted of five (5) residents, group two (2) and three (3) consisted of three (3) residents each. Resident interviews revealed that no concerns were noted or expressed at the time of the visit. Residents reported that a variety of activities are offered and provided, and food substitutions are available upon request. Report Continued on LIC 809-C PAGE 3...

• 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.

Medication Audit: There are two (2) medication rooms located on each side of the facility. Med Techs distribute medication at the appropriate times to residents in care. Medication audit for nine (9) residents was conducted. Six (6) in the Assisted Living Unit and three (3) in the Memory Care Unit of which one (1) on Hospice. The following was observed. The medications were stored in the medication rooms in carts, both were locked and inaccessible to the residents. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. LPA advised ED that a few of the start dates were difficult to read and suggested reviewing / clearing up the writing to make it easily legible. No errors observed during review.

Documents: Documents obtained during the visit include: Limited Liability insurance. LPA obtained the following documents on the initial annual visit on 10/23/2025 : Facility / Staff roster and a Resident roster.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report reviewed and provided.