Routine inspection·April 3, 2025

At approximately 9:50 a.m. on 04/03/2025, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator designee and disclosed the reason for the visit. A file review was conducted prior to today’s visit. The facility was last visited on 03/16/2024 for an annual inspection. 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) nonambulatory residents, of which 1 may be bedridden. The facility serves residents with dementia. Approved hospice waivers for four (04). LPA observed a maintained front yard and postings near the main entrance for the facility’s COVID policies, emergency contacts, confidential complaint contacts, Ombudsman contacts, personal rights, rights of resident councils, theft and loss policy, administrator certificate, facility sketch. LPA observed a screening station with digital thermometer, visitor log, sanitizer, masks, and additional PPE. Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:15 a.m. LPA measured the room temperature to be 77 degrees Fahrenheit. The living room contained a television, reading materials, a locked fireplace, and furniture in good condition. Hallways closets contained emergency food and water and sufficient supplies of fresh linens. The facility has four (04) bathrooms. All bathrooms designated for residents contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid surface in the shower. At approximately 10:30 a.m. LPA measured the water temperature in the hallway bathroom to be 109.8 degrees Fahrenheit. The facility has five (05) bedrooms. All bedrooms were private rooms. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All hospital beds had wheels in the locked position. All furnishings were clean and in good condition. A Hoyer lift, full bed rails, and oxygen machine were observed in Bedroom #3. A sign for “No Smoking – Oxygen in Use” was posted on the door. A call system was in use for Bedroom #5 and routed to the kitchen. At 11:30 a.m. LPA called out from the house telephone which was deemed operational. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter. Cleaning solutions were locked below the sink. Medications were locked above a counter top. Confidential files were locked below the counter top. A washing machine and dryer were located near the kitchen. Both were in working order and in use. The detergent was locked above the appliances. At approximately 11:35 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was purchased on 02/06/25 with a receipt attached. The emergency exit path was free from obstructions. The exit gate on the north side of the facility was unlocked with a self-closing latch. The back yard was maintained. The patio furniture was shaded under a pergola and in good repair. Auditory alarms were turned on and functioning. The facility also uses a centralized auditory alert system. At approximately 11:55 a.m. smoke and carbon monoxide detectors were tested and operational. Detectors were hard-wired and functioned simultaneously when tested. At 12:00 p.m. LPA reviewed resident and personnel files. All files were available for audit. No immediate health and safety risks were observed during this visit. Exit interview conducted. Copy of report provided.