Routine inspection·November 6, 2023

At 11:00 a.m. on 11/06/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out. No immediate health and safety hazards were noted during the time of the visit. At 8:45 a.m. today prior to the visit, a file review was conducted of facility documents including but not limited to the Plan of Operations, Dementia Care Plan, Mitigation Plan, Liability Insurance, Facility Application, Facility Sketch, Fire Clearance, Facility Profile, and Personnel Report. A current copy of the facility’s liability insurance was obtained at 12:30 p.m. today. The facility was last visited on 09/08/2022 for a case management visit. It is a single story building with 6 bedrooms, 2 bathrooms, kitchen, laundry room, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 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). At 11:15 a.m. today, LPA obtained documents including but not limited to the staff roster, resident roster, and resident files for review. At the main entrance, LPA observed a visitor log as well as postings including but not limited to the facility’s visitation policy, non-discrimination notice, a blank copy of the admission agreement, resident rights, rights of resident councils, facility sketch with evacuation routes clearly labeled, and contacts for the Ombudsman and confidential complaints. The facility has 6 bedrooms. 2 bedrooms are designated as staff rooms. The staff rooms were locked 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. The facility has 2 bathrooms. 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. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen and garage refrigerators, freezers, and pantries. The stove hood was clean. Appliances were in good condition. Sharps were locked below the sink. Cleaning solutions were locked in the laundry area. Medications were locked as well. A washing machine and dryer were located near the kitchen. Both were in working order. Detergents were locked above the appliances. Walls, floors, windows, screens, and blinds were clean and in good repair. At 12:10 p.m. LPA measured the room temperature to be 77.5 degrees Fahrenheit. LPA observed a covered patio area in the rear of the facility with one (01) resident utilizing the area. The patio contained furniture in good condition. The ramp which led to the emergency exit was in good repair. All emergency exit paths were free from obstructions. Exit gates were unlocked with self-closing latches. At approximately 12:20 p.m. the dual-purpose smoke and carbon monoxide detector was tested and operational. Between 11:45 a.m. and 12:20 p.m. three (03) out of three (03) auditory alarms were on and functioning. During today's inspection, the facility was in compliance with Title 22 regulations. Exit interview conducted. Copy of report provided.