Routine inspection·June 27, 2025

At approximately 9:30 a.m. on 06/27/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with Staff #1 (S1) and disclosed the reason for the visit. The facility was last visited on 04/20/34 for an annual inspection. It is a single story building with four (04) bedrooms, three (03) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) non-ambulatory residents, of which one (01) may be bedridden in Bedroom #4. The facility serves residents with dementia. Approved hospice waivers for six (06). At the main entrance, LPA observed postings for COVID precautions, personal rights, rights of resident councils, family councils, neighborhood complaint procedures, theft and loss policy, visitation policy, non-discrimination notice, facility sketch and license, confidential complaint contacts, ombudsman contacts, and administrator certificate. At approximately 10:00 a.m., S1 told LPA that today was their first day in the facility. S1 did not know how to access staff and resident files. At approximately 10:10 a.m. LPA observed the resident in Bedroom #1 lying in bed with full bed rails. At approximately 10:12 a.m. LPA observed two (02) bedridden residents in Bedroom #4. S1 confirmed both residents were bedridden. Both residents had full bed rails. Phone call with the administrator at approximately 10:15 a.m. revealed only one resident, Resident #1 (R1), who resided in Bedroom #4, had hospice services and physician orders for full bed rails. The administrator said the other two residents had full bed rails because that was the only bed they had available. The administrator noted neither R1’s roommate, Resident #2 (R2), nor the resident in Bedroom #1, Resident #3 (R3), were enrolled in hospice services. Neither R2 nor R3 had physician orders for full bed rails. Additionally, the administrator noted that they submitted a criminal background clearance transfer request for S1 but they were not yet associated to the facility. S1 was required to work today since the administrator could not be present and the main staff, Staff #2 (S2), was ill. S2 was also the administrator designee. No qualified administrator or designee was in charge of the facility’s operations today. The administrator called Staff #3 (S3) to come to the facility. Record review at 10:18 a.m. today revealed S1 was not associated to the facility and S3 was associated and cleared to work in the facility. S3 arrived at approximately 10:50 a.m. These deficiencies are cited on the corresponding LIC 809-D page. Civil penalties are issued in the amounts of $100 per day per unassociated staff member and a $500 immediate civil penalty for a fire clearance violation. The administrator was notified that additional civil penalties would be issued if the violations are not corrected by the POC due date. Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:20 a.m. LPA measured the room temperature to be 73 degrees Fahrenheit. Puzzles, board games, and art supplies were provided in the living room. At approximately 10:25 a.m., LPA observed a fully charged fire extinguisher near the stove. A receipt was attached from 04/20/2020. The licensee was cited for this same expired fire extinguisher on 04/30/24. The deficiency was never corrected. A new deficiency is cited on the LIC 809-D page. At 10:50 a.m. LPA and S1 tested all auditory alarms. One (03) out of three (03) auditory alarms was operational. This deficiency is cited on the corresponding LIC 809-D page. The facility has three (03) bathrooms. One (01) bathroom is private, and two (02) are shared. Two (02) out of two (02) resident bathrooms 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 mat in the shower. At approximately 11:00 a.m. LPA measured the water temperature in the bathroom near the main entrance to be within regulatory range. The facility has four (04) bedrooms. Two (02) bedrooms are private and two (02) are shared. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator and pantry. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter. Cleaning solutions were locked in a closet near the kitchen. Medications and a complete first aid kit were locked above the washer and dryer. The washing machine and dryer were located in the kitchen. Both were in working order. LPA observed a patio area in the rear of the facility. The patio contained furniture in good condition. Ramps leading out were secure. The emergency exit path was free from obstructions. Two (02) out of two (02) exit gates were unlocked. Exit interview conducted. Appeal rights discussed. Copy of report provided.