Routine inspection·October 17, 2025

At approximately 9:00 a.m. on 10/17/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with the administrator and disclosed the reason for the visit. The facility was last visited on 07/17/25 for a complaint visit. It is a single story building with seven (07) bedrooms, three (03) 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 five (05). Surveillance cameras are used in common areas. The front entrance was gated and unlocked. The front yard was maintained with gardened areas and free of hazards. At the front door, LPA observed postings for the house rules, visitation policy, facility sketch, facility license, COVID precautions, rights of resident councils, personal rights, ombudsman contacts, emergency disaster plan, personal rights, and administrator certificates. A screening station at the front contained a visitor log, sanitizer, digital thermometer, and masks. Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:10 a.m. LPA measured the room temperature to be 72 degrees Fahrenheit. The living room contained a television, reading materials, and furniture in good repair. Activities were set up on the dining room table. Hallway closets contained adequate supplies of fresh linens and extra supplies. A locked closet near the main entrance contained confidential files, medications, and a fully-stocked first aid kit. At 9:20 a.m. LPA successfully called out from the house telephone and deemed it operational. The facility has seven (07) bedrooms. One (01) bedroom served as a staff room. The staff room was 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. Exit doors from rooms were unlocked. A resident in Bedroom #3 had full bed rails. The facility has three (03) bathrooms. Two (02) bathrooms are private, and one (01) is shared. Bathrooms contained liquid soap, trash cans with tight fitting lids, bidets, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 9:30 a.m. LPA measured the water temperature in the shared bathroom to be 118.2 degrees Fahrenheit. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen refrigerators, freezers, and pantry. A weekly menu was posted on the refrigerator. At 11:35 a.m. LPA measured the refrigerator temperature to be 34 degrees Fahrenheit. Appliances were clean and in good condition. Sharps were locked below the counter top. Cleaning solutions and detergents were locked in the laundry area adjacent to the kitchen. The laundry area contained a washing machine and a dryer in working order. At 11:40 a.m. LPA observed three (03) residents in the living room watching television. Lunch was served at 11:45 a.m. Lunch was observed to contain a variety of nutritious proteins, fruits, and grains. LPA overheard the administrator offering residents multiple choices for lunch. At 12:45 p.m. the combination carbon monoxide and smoke detectors were tested and operational. At 12:55 p.m. a fully-charged fire extinguisher was observed in the kitchen. Four (04) out of four (04) auditory alarms were on and functional. Two (02) seating areas in the rear were shaded with furniture in good repair. One of the seating areas had a mosquito net around it. The back yard also contained a gardened area, exercise equipment, and a gas grill. The garage was locked and contained tools and extra supplies. A shed was also locked and contained additional supplies. The emergency exit path was free of hazards. The exit gate was unlocked. At 12:30 p.m. LPA conducted a records review of resident and personnel files. All files were complete and available for audit. During today’s inspection, no immediate health or safety hazards were observed. Exit interview conducted. Copy of report provided.