Routine inspection·February 24, 2026

At approximately 12:55 p.m. on 02/24/26, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and disclosed the reason for the visit. A file review was conducted prior to the visit. The facility was last visited on 02/05/25 for an annual inspection. It is a single story building with six (06) bedrooms, four (04) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents. Approved hospice waivers for six (06). At the main entrance, LPA observed a maintained front yard with stairs leading to the unlocked main entrance. The driveway was free of debris. Postings were observed for confidential complaint contacts, ombudsman contacts, personal rights, rights of resident councils, nondiscrimination notice, neighborhood grievance procedure, emergency disaster plan, facility license, facility sketch, administrator certificate, and a blank copy of an admission agreement. A sign showing “No smoking – Oxygen in use” was posted at the main entrance. Walls, floors, windows, screens, and blinds were clean and in good repair. The living room contained furniture in good repair, reading material, puzzles, art supplies, and exercise equipment. An office was locked and contained confidential files and medications. A linen closet near Bedroom #4 contained an adequate supply of fresh linens, PPE, and hygiene supplies. A locked closet near the office contained medications and a fully stoked first aid kit. Four (04) out of four (04) auditory alarms were tested and functional. LPA observed a covered patio area in the rear of the facility. At approximately 1:15 p.m. the room temperature to be 76 degrees Fahrenheit. The facility has six (06) bedrooms. Bedroom #6 is designated as a staff room. The staff room was free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All beds with wheels were maintained in the locked position. The facility has four (04) bathrooms. One (01) bathroom is designated for staff, and three (03) others are shared for residents. All bathrooms contained liquid soap, paper towels, trash cans, grab bars near the toilet and shower, and a non-skid mat or non-skid surfaces in the showers. At 1:25 p.m. LPA measured the water temperature in the bathroom near Bedroom #5 to be 108.5 degrees Fahrenheit. At approximately 1:40 p.m., smoke and carbon monoxide detectors were tested and operational. Two (02) out of two (02) smoke alarms were hard-wired and functioned simultaneously. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen refrigerator and freezer. A pantry near Bedroom #3 contained additional non-perishable food supplies. The stove hood was clean. Appliances were in good condition. Sharps were locked below the stove. Cleaning solutions were locked below the sink. A washing machine and dryer were located adjacent to the kitchen. Both were in working order. Detergents were locked above the washer. At 1:50 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 05/16/25 with a tag attached. LPA called out from the house telephone at 1:55 p.m. and was deemed operational. All emergency exit paths were free from obstructions. Two (02) out of two (02) exit gates were unlocked. The garage was unlocked and free of hazards. The patio contained furniture in good condition. At 2:10 p.m., LPA reviewed resident and personnel files. All files were complete and available for audit. Additionally, LPA reviewed the updated certificate of liability insurance which expires 07/03/26. During today’s inspection, no immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.