Routine inspection·May 21, 2025

At approximately 1:05 p.m. on 05/21/2025, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and disclosed the reason for the visit. The facility was last visited on 04/30/24 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). The main entrance gate was unlocked and open. A courtyard led to the front door. The front yard had maintained gardened areas. 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 complaint 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 had 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. All hospital beds had wheels in the locked position. The facility had 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 non-skid mats in the shower. At approximately 1:20 p.m. LPA measured the water temperature in the bathroom nearest to Bedroom #4 to be 112.3 degrees Fahrenheit. Walls, floors, windows, screens, and blinds were clean and in good repair. At 1:40 p.m. LPA measured the room temperature to be 77 degrees Fahrenheit. Two (02) residents were observed sleeping. One (01) resident was watching television. One (01) other resident had a friend over for visitation. The dining room contained board games, art supplies, a puzzle, 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. At 2:05 p.m. LPA called out from 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 in the laundry room adjacent to the kitchen. The laundry room was locked and contained a washing machine and dryer were in working order. LPA observed two (02) covered patio areas 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. Two (02) out of two (02) emergency exit paths were free from obstructions. Two (02) out of two (02) exit gates were unlocked. Four (04) out of four (04) auditory alarms were turned on and functioning. At approximately 2:15 p.m., the smoke and carbon monoxide detector was tested and operational. At approximately 2:30 p.m. LPA observed a fully charged fire extinguisher in the laundry room. It was last inspected on 05/26/24. The garage was locked and contained extra food supplies, emergency water supplies, resident belongings, mobility devices, an additional refrigerator, tools, and cleaners which were stored away from the food. At 2:30 p.m. today, LPA conducted a record review of resident and personnel files. All required files were current and available for audit. 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.