Routine inspection·April 23, 2026

At approximately 9:40 a.m. on 04/23/26, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit. The facility was last visited on 04/02/25 for an annual 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). At 9:50 a.m. LPA reviewed resident and personnel files. All files were complete and available for audit. LPA observed a maintained front yard and postings at the main entrance for the facility’s COVID and visitation policy. 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, a blank copy of the admission agreement, 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 10:00 a.m. LPA measured the room temperature to be 73 degrees Fahrenheit. Three (03) residents were engaged in activities at the dining table and one (01) was watching television. The living room contained karaoke, a television, reading materials, puzzles, and furniture in good condition. A fireplace was appropriately covered and turned off. A locked cabinet near the television 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, and a bed with adequate bedding. All hospital-style beds had wheels in the locked position. All furnishings were clean and in good condition. A Hoyer lift was observed in Bedroom #2. The facility has 2 bathrooms. All bathrooms contained liquid soap, paper towels, 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 11:20 a.m. LPA measured the water temperature to be 107.2 degrees Fahrenheit in the shared bathroom near Bedroom #2. LPA observed an adequate supply of perishable, non-perishable, and emergency 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 11:30 a.m. LPA conducted a medication review of one (01) resident. All medications were maintained in the proper quantities. A washing machine and dryer were located in the kitchen. Both were in working order and in use. Detergents were locked under the sink. 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. Four (04) out of four (04) auditory alarms were turned on and functioning. At approximately 11:45 a.m. smoke and carbon monoxide detectors were tested and operational. When tested, two (02) out of two (02) fire doors closed completely. At approximately 11:50 a.m. LPA observed a fully charged fire extinguisher in the kitchen. Fire sprinklers were observed throughout the facility. The ramp leading out form Bedrooms #2 and #3 were stable with secure handrails. The garage was locked and contained emergency water and food, an additional refrigerator and freezer, and extra supplies. At 11:50 p.m. LPA called out from the house telephone which was deemed operational. No immediate health and safety risks were observed during this visit. Exit interview conducted. Copy of report provided.