Routine inspection·July 2, 2025

At 8:45 a.m. on 07/02/2025, 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. LPA and the adinistrator toured the facility inside and out. The facility was last visited on 06/14/24 for an annual visit. It is a single story building with five (05) bedrooms, four (04) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) residents, of which five (05) may be nonambulatory and one (01) bedridden. The facility serves residents with dementia. Approved hospice waivers for six (06). At the main entrance, LPA observed postings for the facility’s visitation policy, emergency disaster plan, facility sketch and license, personal rights, and blank copy of the admission agreement. Additional postings were observed inside for confidential complaint contacts, emergency contacts, rights of resident councils, and ombudsman contacts. A screening station at the front contained a visitor log. Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:00 a.m. LPA measured the room temperature to be 75 degrees Fahrenheit. At approximately 9:25 a.m., smoke and carbon monoxide detectors were tested and operational. At approximately 9:30 a.m. the licensee called the house telephone, which was deemed to be operational. At 9:35 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 05/07/25 and had a tag attached. Five (05) out of five (05) residents were observed participating in activities in the living room together. Interview with the administrator at 9:45 a.m. today revealed the facility hired an activity coordinator who comes twice a week and a musician who comes once a week. The living room also contained a piano, musical equipment, reading material, art supplies, and exercise equipment. Hallway closets had board games, puzzles, and art supplies, PPE, and an adequate supply of fresh linens. Night lights were hung throughout the hallways. The facility had five (05) bedrooms. The bedroom nearest the main entrance is designated as a staff room. The staff room was locked and free of hazards. Of the four (04) resident bedrooms, two (02) are shared and two (02) are private. Bedroom #2 and Bedroom #4 had appropriate signs stating “No smoking – Oxygen in use”. Bedroom #3 and Bedroom #4 had private bathrooms. All bedrooms contained a chair, lamp, nightstand, storage, activity calnedars, call buttons, and a bed with adequate bedding. All furnishings were clean and in good condition. At approximately 10:00 a.m. the call button in Bedroom #1 was tested and deemed operational. The facility has four (04) bathrooms. Staff use the large bathroom nearest the main entrance to assist with bathing residents. All bathrooms contained liquid soap, paper towels, trash cans with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. Commodes and shower chairs were also available. At approximately 10:15 a.m. LPA measured the water temperature to be within regulatory range. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. Appliances were in good condition. The administrator noted the microwave was promptly fixed after last year’s annual inspection. Cleaning solutions were locked below the sink and in a separate cabinet near the staff room. Sharps were locked in a lock box below the counter top. Medications were locked in a cabinet near the refrigerator. At approximately 10:30 a.m. a medication review was performed for three (03) residents. All medications were stored in the correct quantities. A washing machine and dryer were located outside of the kitchen. Both were in working order. Detergents were locked in a storage container next to the appliances. LPA observed a covered, shaded patio area in the rear of the facility. The patio contained furniture in good condition. Ramps were secure and had sturdy hand rails. Ramps led out from the living room and Bedroom #3. The emergency exit path was free from tripping hazards. There was a locked storage shed with gardening supplies. The pool was fenced, locked, and inaccessible. The exit gate was unlocked with a self-closing, inward facing latch. Evacuation routes were posted. Four (04) out of four (04) auditory alarms were turned on and functioning. At 10:45 a.m. LPA reviewed resident and personnel files. Files were complete 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.