Routine inspection·April 30, 2024

At 8:35 a.m. on 04/30/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator and disclosed the reason for the visit. The facility was last visited on 05/03/2022 for an annual inspection. It is a single story building with five (05) bedrooms, three (03) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) residents, of which six (06) may be non-ambulatory. The facility serves residents with dementia. Approved hospice waivers for three (03). At 8:45 a.m. today, LPA conducted a record review of resident and personnel files. All required files were available for inspection and up to date. After the administrator arrived at 9:35 a.m. LPA and administrator toured the facility inside and out. The main entrance had two unlocked gates and a courtyard leading to the front door. The front yard had gardened areas, a fountain with no water, and a semicircle driveway. Once inside, LPA observed postings for confidential complaint contacts, Ombudsman contacts, emergency disaster plan, facility sketch and license, rights of resident councils, personal rights, neighborhood complain procedures, and a blank copy of an admission agreement. A sign stating “No smoking – Oxygen in use” was also posted at the front door. The facility has five (05) bedrooms. One (01) bedroom is designated as a staff room. The staff room was free of hazards. Bedrooms #4 and #1 were shared. Bedrooms #5 and #3 were private. The ramp and handrail in Bedroom #1 were secure. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:40 a.m. LPA measured the room temperature to be 70 degrees Fahrenheit. Two (02) residents were observed eating breakfast in the dining room. The dining room contained board games and furniture in good repair. The living room contained reading material, a massage chair, a couch, and a television. Night lights were observed in the hallways. The facility has three (03) bathrooms. The resident bathrooms contained liquid soap, trash cans with tight fitting lids, grab bars near the toilet and shower, commodes, shower chairs, and a non-skid mat in the shower. At approximately 9:55 a.m. LPA measured the water temperature in the bathroom nearest to Bedroom #1 to be 116.4 degrees Fahrenheit. At 10:00 a.m. LPA called the house telephone. It was deemed operational. LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator, freezer, pantry, and garage. Appliances were in good condition. Sharps were locked below the counter top. A water temperature log was observed on the wall. Cleaning solutions were locked in the laundry room adjacent to the kitchen. The washing machine and dryer were in working order. LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition, exercise equipment, and a gas grill which was turned off. The pool was gated and locked with a padlock. All emergency exit paths were free from obstructions. Exit gates were unlocked. Auditory alarms were turned on and functioning at the front, rear, and resident rooms. At approximately 10:20 a.m., the smoke and carbon monoxide detector was tested and operational. At approximately 10:30 a.m. LPA observed a fully charged fire extinguisher in the laundry room. It was last inspected on 05/05/2023. The garage was locked and contained extra food supplies, emergency water supplies, resident belongings, mobility devices, an additional refrigerator, and cleaners which were stored away from the food. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.