Routine inspection·January 21, 2025

At 8:50 a.m. on 01/17/2025, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and later the administrator and disclosed the reason for the visit. The facility is a two-story building with private and shared bedrooms, private and public bathrooms, common areas, activity rooms, living rooms on both floors, dining room, laundry areas on both floors, and outdoor areas. It has an approved fire clearance for thirty (30) ambulatory residents and sixty (60) nonambulatory residents, of which fifteen (15) may be bedridden. Approved hospice waivers for thirty (30) residents. At 9:15 a.m. LPA reviewed resident and personnel files. All files and physician orders were complete and available for audit. LPA also reviewed updated liability insurance good through 07/01/25, in-service trainings, and passed quarterly and annual fire inspection tests from 11/19/24. LPA observed signs near the main entrance and throughout the building for COVID precautions, visitation policy, emergency disaster plan, Ombudsman contacts, confidential complaint contacts, theft and loss policy, house rules, resident rights, rights of resident councils, facility sketch with evacuation routes, daily, monthly, and alternate menus, activity schedules, emergency contacts, and nondiscrimination policy. The lobby area was clean and contained appropriate seating, visitor logs, and a reception area. The main activity room near the main entrance contained furniture in good repair, a piano, reading material, and a television. Cameras were observed common areas and exterior areas. The outdoor area was accessible from the television room. The outdoor area contained patio furniture in good repair and was shaded by umbrellas. At approximately 11:45 a.m. LPAs observed a fully charged fire extinguisher near the front lobby. It was last serviced on 02/05/2024. Another activity room near the dining room contained music, art supplies, board games, a new vending machine, and exercise equipment. The upstairs area also had a separate activity room. Public restrooms were clean and fully stocked with liquid soap, paper towels, and trash cans with tight fitting lids. The janitorial closet, storage rooms, and employee lounge were locked and inaccessible. A linen closet was also observed in the first floor hallway and contained an adequate supply of fresh sheets and beddings. The first floor laundry area was locked and contained two (02) operable washers, two (02) dryers, and detergents. Another laundry room was located on the second floor and was free of hazards. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. A daily menu and an alternate menu were posted in the dining room. Modified diet cards were posted according to updated physician orders. Emergency water and food supplies were observed in a separate room and in ample amount. At 12:10 p.m., the walk-in refrigerator and freezer temperatures were measured to be 32 degrees and -5 degrees Fahrenheit. Kitchen staff also maintained temperature logs for cooling and heating appliances. The house telephone was used to call and deemed operational at approximately 12:15 p.m. LPA inspected Room #113, 118, and 226. Bedrooms were sanitary and free of hazards. Resident bathrooms and showers contained grab bars, liquid soap, personal towels, trash cans, and non-skid mats and strips. Resident rooms contained chairs, nightstands, lamps, call systems, and beds with furnishings in good condition. “No Smoking – Oxygen in Use” signs were observed in appropriate rooms. Facility call system tests were conducted in Room #113 at 11:55 a.m. and in Room #226 at 12:37 p.m. Staff responded to each call system test within two (02) minutes. At 12:00 p.m. and 12:30 p.m., LPA measured the water temperatures in the resident bathrooms to be 117.1 and 114.8 degrees Fahrenheit. Fire sprinklers, alarms, and extinguishers were located throughout the facility. LPA also observed a designated smoking area upstairs with appropriate signage, air filters, and plants. Another designated smoking area was observed on the first floor in the rear of the facility near a gardened area. Two (02) storage sheds outside were inaccessible as well. At approximately 12:45 p.m. a carbon monoxide detector was tested and operational. Three (03) out of three (03) emergency exits were unlocked, and all emergency exit paths were free of hazards. Emergency chairs were observed in two (02) out of two (02) stairwells. Delayed egresses on both stairwells were tested and operational. The medication room was made inaccessible and contained a complete first aid kit, a medication refrigerator, a locked medication cart, and disposal bins for sharps. A medication review was conducted around 1:00 p.m. Three (03) out of three (03) resident medication supplies reviewed had correct amounts of medications to today’s date. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Copy of report provided.