Routine inspection·April 2, 2025

At 9:45 a.m. on 04/02/2025, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit. A file review was conducted prior to today’s visit. The facility was last visited on 04/16/2024 for an annua inspection. It is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which 1 may be bedridden in Bedroom #2. The facility serves residents with dementia. Approved hospice waivers for three (03). LPA observed a maintained front yard and postings at the main entrance for the facility’s COVID and visitation policies. Inside the main entrance, LPA observed postings for emergency contacts, confidential complaint contacts, Ombudsman contacts, personal rights, theft and loss policy, administrator certificate, facility sketch with evacuation routes posted, visitation policy, non-discrimination notice, a blank copy of the admission agreement, activity schedule, and COVID postings. LPAs observed a screening station with digital thermometer, visitor log, sanitizer, masks, and additional PPE. Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:50 a.m. LPA measured the room temperature to be 76 degrees Fahrenheit. Four (04) residents were engaged in activities at the dining table. The living room contained karaoke, exercise equipment, television, reading materials, and furniture in good condition. A fireplace was appropriately covered and turned off. At 9:55 a.m. LPA called out from the house telephone which was deemed operational. The call system was centrally routed to the living room as well. A locked cabinet contained confidential files. A closet in the hallway contained a sufficient supply of fresh linens and incontinence supplies. The facility has four (04) bedrooms. Bedroom #1 and Bedroom #2 are shared. Bedroom #3 and Bedroom #4 are private. All bedrooms contained a chair, lamp, nightstand, storage, fall prevention mats, and a bed with adequate bedding. All hospital beds had wheels in the locked position. All furnishings were clean and in good condition. A Hoyer lift was observed in Bedroom #2. The bed in Bedroom #3 had full bed rails which were not in use at the time. The facility has 2 bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, bidets, commodes, and a non-skid surface in the shower. At approximately 10:10 a.m. LPA measured the water temperature to be 114.3 degrees Fahrenheit. The resident bathroom toilet has the toilet seat and lid removed and used a commode to cover the bowl. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen and garage. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter. Cleaning solutions were locked below the sink. Medications were locked in a cabinet in the kitchen. At 10:20 a.m. LPA conducted a medication review of two (02) residents. All medications were administered properly. A washing machine and dryer were located in the kitchen. Both were in working order and in use. The emergency exit path was free from obstructions. The exit gate was unlocked with a self-closing latch. The back yard was maintained and had fruit-bearing trees. The patio furniture was shaded and in good repair. A locked shed contained cleaning supplies. Five (05) out of five (05) auditory alarms were turned on and functioning. At approximately 10:45 a.m. smoke and carbon monoxide detectors were tested and operational. At approximately 10:50 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 08/16/2024. Fire sprinklers were observed throughout the facility. Surveillance cameras were present on the exterior of the home. Ramps were stable with secure handrails. The garage was locked and contained emergency water and food, an additional refrigerator and freezer, and extra supplies. At 11:30 a.m. LPA reviewed resident and personnel files. All files were complete and available for audit. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed during this visit. Exit interview conducted. Copy of report provided.