Routine inspection·March 4, 2026

At approximately 9:00 a.m. on 03/04/26, 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) non-ambulatory residents, of which fifteen (15) may be bedridden. Approved hospice waivers for thirty (30) residents. The administrator noted ongoing renovations including additional laundry appliances upstairs, as well as kitchen and dining room repairs. LPA observed postings near the main entrance and medication room 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, weekly menus, activity schedules, emergency contacts, and nondiscrimination policy. The front yard was maintained. The lobby area was clean and contained appropriate seating, visitor logs, water, a mounted digital thermometer, mailboxes, and a reception area. The 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 front outdoor area was accessible from the television room. The outdoor area contained patio furniture in good repair and was shaded by umbrellas. At approximately 9:20 a.m. LPA observed fully-charged fire extinguishers near the front lobby, kitchen, and in the upstairs and downstairs hallways. They were last serviced on 02/13/26 and had tags attached. Another activity room near the dining room contained music supplies, art supplies, board games, a new vending machine, a billiards table, and exercise equipment. The upstairs area also had an activity room with pianos, furniture, and reading material. The designated smoking area was adjacent to the upstairs activity room with a newly installed fan to diminish smoke. Public restrooms were clean and fully stocked with liquid soap, paper towels, and trash cans with tight fitting lids. At 9:30 a.m., the temperature of the first-floor public restroom was measured to be 109.6 degrees Fahrenheit. The janitorial closet, storage rooms, and employee lounge were locked and inaccessible. The elevator was operable. 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 dietary cards were posted according to updated physician orders. Emergency water and food supplies were observed in a separate room and in ample amount. At 10:00 a.m., the walk-in refrigerator temperature was measured to be 38 degrees. The walk-in freezer was inoperable, so additional freezers were provided in the medication room and kitchen. At 11:30 a.m. the freezer temperature was measured to be -10 degrees Fahrenheit. Kitchen staff also maintained temperature logs for cooling and heating appliances. LPA inspected Room 115 and 219. 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 219 at 10:18 a.m. and in Room 115 at 10:37 a.m. Staff responded to each call system test within two (02) minutes. LPA also heard the receptionist announce the call lights over the intercom within one (01) minute. At approximately 10:20 a.m. and 10:40 a.m., LPA measured the water temperatures in the resident bathrooms to be 112.5 and 111.7 degrees Fahrenheit. Fire sprinklers, alarms, and extinguishers were located throughout the facility. Two (02) storage sheds outside were inaccessible as well and contained extra supplies. Three (03) out of three (03) emergency exits were unlocked. 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, locked medication carts, disposal bins for sharps, and locked PRN and hospice medications. A refrigerator contained residents snacks. A medication review was conducted around 12:00 p.m. Six (06) out of six (06) resident medications were stored in the correct quantities. At 12:45 p.m. LPA reviewed resident and personnel files. All files and physician orders were complete and available for audit. LPA also reviewed updated liability insurance, in-service trainings, dietitian reports, and annual fire inspection tests from 01/08/26. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Copy of report provided.