Routine inspection·February 8, 2024

At 10:10 a.m. on 02/08/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator and disclosed the reason for the visit. LPA and administrator toured the facility inside and out at 10:45 a.m. A file review was conducted prior to today’s visit. The facility was last visited on 02/14/2023 for a complaint visit. It is a single story building with seven (07) bedrooms, three (03) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 nonambulatory residents, of which six (06) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for four (04). Surveillance cameras are used in common and exterior areas. The front access was gated with a doorbell for entry. LPA observed a maintained front yard and a ramp in good condition leading to the main entrance. Postings at the front included COVID precautions, administrator certificate, facility license, facility sketch, admission agreement, confidential complaints contacts, ombudsman contacts, emergency disaster plan, rights of resident councils, personal rights, theft and loss policy, resident list, and “No smoking – Oxygen in use” sign. A screening station was located at the main entrance. It contained a digital thermometer, visitor log, masks, and sanitizer. Walls, floors, windows, screens, and blinds were clean and in good repair. At 11:00 a.m. LPA measured the room temperature to be 73.1 degrees Fahrenheit. Two (02) residents were observed in the living room watching television. Two (02) staff members were observed cleaning and preparing lunch. A whiteboard was hung in the living room denoting the date, staff present, and meal, snack, and activity times for the day. Board games, puzzles, and other activities were provided. A fireplace was appropriately grated and turned off. Medications were locked near the main entrance. Two (02) hallway closets contained extra linens and towels. A locked office in the rear of the facility contained personnel and resident files. The facility has seven (07) bedrooms. One (01) bedroom is designated as a staff room. The staff room was 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 three (03) bathrooms. One (01) bathroom is private to Bedroom #3, and two (02) are shared. All 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 12:30 p.m. LPA measured the water temperature in Bathroom #1 to be 112.2 degrees Fahrenheit. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. Appliances were in good condition. Sharps and cleaning solutions were locked under the sink. A washing machine and dryer were located in the garage. Both were in working order. Detergents, incontinence supplies, extra mattresses were also stored in the garage. LPA observed two (02) covered patio areas in the rear and side of the facility. The patios contained furniture in good condition. Also observed were potted plants, workout equipment, and a pool which was filled in with cement. All emergency exit paths were free from obstructions. Exit gates were unlocked. Eight (08) out of eight (08) auditory alarms were turned on and functioning. Fire sprinklers were located throughout the facility. At 12:25 p.m., smoke and carbon monoxide detectors were tested and operational. At approximately 12:35 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was purchased on 07/17/2023 with a receipt attached. At approximately 1:30 p.m. LPA and administrator discussed upcoming renovations and necessary repairs to the facility in the upcoming months. Residents will be relocated to an alternate licensed facility for approximately 2 months during the repairs. Families, physicians, and residents have all been informed and provided consent to the plans. At 2:00 p.m. LPA reviewed staff and resident files. During today's inspection, the facility was in compliance with Title 22 regulations. Exit interview conducted. Copy of report provided.