Routine inspection·July 24, 2025

At approximately 8:50 a.m. on 07/24/2024, 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 07/09/2024 for an annual inspection. It is a single story building with six (06) bedrooms, two (02) bathrooms, kitchen, laundry room, garage, 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). At the main entrance and near the kitchen, LPA observed a visitor log as well as postings including but not limited to the facility’s visitation policy, a blank copy of the admission agreement, resident rights, rights of resident councils, facility sketch with evacuation routes clearly labeled, emergency disaster plan, house rules, and contacts for the Ombudsman and confidential complaints. The facility had six (06) bedrooms. Two (02) bedrooms were 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. Five (05) out of six (06) hospital beds had wheels in the locked position. One (01) hospital bed had inoperable brakes, and the administrator ordered a new bed during the visit. The facility had two (02) bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instructions sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 9:15 a.m. LPA measured the water temperature in Bathroom #1 to be 119.3 degrees Fahrenheit. Walls, floors, windows, screens, and blinds were clean and in good repair. The living room contained furniture in good repair, an appropriately covered fireplace, and a piano. LPA observed four (04) residents watching television together. Reading materials, art supplies, and exercise equipment. At 9:20 a.m. LPA measured the room temperature to be 73 degrees Fahrenheit. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen and garage refrigerators, freezers, and pantries. The garage was locked and inaccessible. The stove hood and surface were clean. Appliances were in good condition. Sharps were locked under a counter. Cleaning solutions were locked in the laundry area. Medications were locked above the counter. At approximately 9:30 a.m., staff and LPA conducted a medication review for three (03) residents. All resident medications were stored and accounted for in the correct quantities. A washing machine and dryer were located near the kitchen. Both were in working order. Detergents were locked above the appliances. At approximately 10:30 a.m. LPA observed a fully charged fire extinguisher in the laundry area. All emergency exit paths were free from obstructions. The exit gate was unlocked with a self-closing latch. At approximately 11:00 a.m. the dual-purpose smoke and carbon monoxide detector was tested and operational. Facility detectors are hard-wired and functioned simultaneously during the test. The fire door near the main entrance closed during the test as well. Between 11:10 a.m. and 11:30 a.m. four (04) out of four (04) auditory alarms were tested to be on and functioning. The house telephone was called at 11:35 a.m. and deemed operational. LPA observed three (03) covered patio areas on the side and rear of the facility. The patios contained furniture in good condition. The ramp which led to the emergency exit was in good repair with a sturdy handrail. LPA reviewed resident and personnel files. All files were complete and available for audit. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health or safety concerns were observed. Exit interview conducted. Copy of report provided.