Routine inspection·January 7, 2025

At 10:10 a.m. on 01/07/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit. A file review was conducted prior to today’s visit. The facility was last visited on 02/23/2024 for an annual inspection. It is a single story building with six (06) bedrooms, four (04) bathrooms, kitchen, laundry room, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which one (01) may be bedridden. Approved hospice waivers for two (02). The facility serves residents with dementia. Four (04) out of four (04) auditory alarms were observed on and functioning LPA observed a maintained front yard with gardened plants, a shaded seating area, and an unlocked front gate. A screening station at the front contained surgical masks, sanitizer, a digital thermometer, and a visitor log. Postings at the front included COVID precautions, visitation policy, facility license, confidential complaints contacts, ombudsman contacts, emergency disaster plan, rights of resident councils, personal rights, theft and loss policy, and the facility sketch. Walls, floors, windows, screens, and blinds were clean and in good repair. Cameras are used in common areas. The living room was clean and had furniture in good repair, board games, and reading materials. Hallway closets contained a sufficient supply of emergency food. Another closet was locked and contained cleaning supplies and PPE. The laundry area was inaccessible and contained an operable washer and dryer and detergents. Medications and confidential files were locked and inaccessible. Both were stored in the living room. The facility has six (06) bedrooms. One (01) bedroom is designated as a staff room. The staff room was unlocked and 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. Rooms with hospital beds had wheels in the locked position. LPA used the house telephone at 10:35 a.m. The phone was deemed operational. At 10:40 a.m., LPA measured the refrigerator temperature to be forty (40) degrees Fahrenheit. Adequate supplies of perishable and non-perishable foods were observed in the kitchen refrigerator and freezer and an additional refrigerator outside. Appliances were in good condition. The stove surface and hood were clean. Sharps were locked below the counter top and cleaners were locked below the sink. At 10:45 a.m. LPA observed a fully charged fire extinguisher. It was last inspected on 05/03/24. The facility has four (04) bathrooms. One (01) bathroom is private to Bedroom #3. Shared bathrooms were located near Bedroom #2. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 10:55 a.m. LPA measured the water temperature to be 116.4 degrees Fahrenheit. LPA observed a patio area in the rear of the facility. The patio contained furniture in good condition. The outdoor areas contained fruit trees and walkways which were free of hazards. The exit gate was unlocked. At approximately 11:15 a.m., smoke and carbon monoxide detectors were tested and operational. At about 11:30 a.m. LPA reviewed staff and resident files. All files were complete and available for audit. No immediate health or safety hazards were observed during today’s visit. The facility is in compliance with Title 22 Regulations. Exit interview conducted. Copy of report provided.