Routine inspection·July 10, 2024

At 1:10 p.m. on 07/10/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with administrator and disclosed the reason for the visit. LPA and administrator toured the facility inside and out. The facility was last visited on 03/05/24 for a complaint visit. It is a single story building with four (04) bedrooms, four (04) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which one (01) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for six (06). At the main entrance, LPA observed a maintained front area and driveway. Postings were observed inside for confidential complaint contacts, emergency contacts, Ombudsman contacts, rights of family and resident councils, personal rights, employee rights, facility license, and facility sketch with evacuation routes clearly labelled. Walls, floors, windows, screens, and blinds were clean and in good repair. At approximately 1:30 p.m. LPA measured the room temperature to be 72 degrees Fahrenheit. A storage room was locked and contained confidential files and medications. The living room contained board games, activities, an appropriately grated fireplace, puzzles, and a television. Three (03) residents were observed eating a meal together. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. At approximately 1:45 p.m. the refrigerator and freezer temperatures were measured to be 38 degrees Fahrenheit and -2.2 degrees Fahrenehit. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter. Cleaning solutions were locked in a cabinet near the washer and dryer. A laundry area near the kitchen contained a washing machine and dryer in working order. Detergents were locked in a cabinet next to the appliances. The facility has four (04) bedrooms. Three (03) bedrooms are private and one (01) is shared. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Bedroom #2 had a sign posted for “No smoking – Oxygen in Use”. Bedroom #1 and Bedroom #3 have private bathrooms. There is a shared bathroom outside of Bedroom #2 and a half bathroom near the laundry area. 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 2:10 p.m. LPA measured the water temperature in the shared bathroom to be 108.9 degrees Fahrenheit. LPA observed a covered patio area in the rear of the facility. A mosquito net covered the sliding glass door separating the living room from the outside area. The patio was shaded and contained furniture in good condition and had a gardening area. The emergency exit path and ramp leading out were free of tripping hazards. The exit gate was unlocked with an inward facing, self-closing latch. The pool in the back yard was fenced, locked, and inaccessible. A storage shed in the area contained gardening supplies and was also inaccessible. Auditory alarms were turned on and functioning. At approximately 2:30 p.m., smoke and carbon monoxide detectors were tested and operational. At approximately 3:00 p.m. LPA observed a fully charged fire extinguisher in the laundry area. At 3:05 p.m. LPA reviewed resident and personnel files. Two (02) out of two (02) staff had First Aid/CPR certifications which had expired on 06/08/2024. A deficiency is issued on the attached LIC 809-D page. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.