Routine inspection·August 12, 2025

At 11:30 a.m. on 08/12/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and disclosed the reason for the visit. The facility was last visited on 07/23/24 for an annual visit. It is a single story building with six (06) bedrooms, three (03) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) residents, of which five (05) may be non-ambulatory and one (01) bedridden in Bedroom #5. The facility serves residents with dementia. Approved hospice waivers for six (06). The front yard was maintained. At the main entrance, LPA observed postings for the facility license, rights of resident councils, personal rights, resident rights, emergency disaster plan, emergency contacts, confidential complaint contacts, ombudsman contacts, house rules, administrator certificates, facility sketch, and a blank copy of the admission agreement. A screening station at the front contained a visitor log, digital thermometer, and hand sanitizer. Walls, floors, windows, screens, and blinds were clean and in good repair. At 12:50 p.m. LPA measured the room temperature to be 76 degrees Fahrenheit. The living room contained board games, reading materials, a television, karaoke machine, emergency water, and furniture in good condition. The fireplace was appropriately covered. Two (02) residents were observed eating lunch in the dining room. Night lights were on in hallways. A linen closet contained an adequate supply of fresh linens and bedsheets. The facility has six (06) bedrooms. One (01) bedroom is designated as a staff room. The staff room was locked and free of hazards. All bedrooms contained a chair, nightstand, lamp, storage, call button, and a bed with adequate bedding. All furnishings were clean and in good condition. All hospital-style beds had wheels in the locked position. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen and detached garage. The stove hood was clean. Appliances were in good condition. At approximately 12:55 p.m. LPA observed a fully charged fire extinguisher near the kitchen. It was last inspected on 08/20/24. Sharps were locked below the counter. Cleaning solutions were locked above the washer and dryer. Medications were locked above the counter top. The washing machine and dryer were both in working order. At 1:00 p.m., LPA and staff conducted a medication review for three (03) residents. All resident medications were maintained in the correct quantities. The facility has four (04) bathrooms. Two (02) bathrooms are private, and two (02) are shared. All bathrooms contained liquid soap, paper towels, trash can with a lid, grab bars near the toilet and shower or a commode, and a non-skid mat in the shower. At approximately 1:15 p.m. LPA measured the water temperature in the shared bathroom near Bedroom #3 to be 105.4 degrees Fahrenheit. LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition. The ramp leading out was free of debris and had sturdy rails. Two (02) out of two (02) emergency exit paths were free from obstructions. Evacuation routes were posted. Four (04) out of four (04) auditory alarms were turned on and functioning. At approximately 1:30 p.m., smoke and carbon monoxide detectors were tested and operational. All detectors functioned simultaneously, and the fire door in the hallway closed. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.