Routine inspection·April 24, 2025

At approximately 9:30 a.m. on 04/24/2025, 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. A file review was conducted prior to today’s visit. The facility was last visited on 07/26/2023 for a prelicensing visit. It is a single story building with three (03) bedrooms, two (02) bathrooms, kitchen, laundry area, common areas, and outdoor areas. It has an approved fire clearance for two (02) ambulatory residents and four (04) nonambulatory residents, of which one (01) may be bedridden in Bedroom #3. Approved hospice waivers for six (06). LPA observed a maintained front yard and an unlocked perimeter gate. A screening station at the front contained surgical masks, sanitizer, a digital thermometer, and a visitor log. Postings at the front and in the kitchen included the facility license, confidential complaints contacts, ombudsman contacts, emergency disaster plan, rights of resident councils, personal rights, weekly menu, activity schedule, theft and loss policy, house rules, and the facility sketch. Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:45 a.m. LPA measured the room temperature to be 72 degrees Fahrenheit. Two (02) residents were observed in the living room drinking tea. A fireplace was appropriately covered. Board games, art supplies, and a television were also provided in the living room. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. Emergency food and water supplies were stored in a pantry near the refrigerator. Appliances were in good condition. Sharps were locked under the counter top. At approximately 9:55 a.m. LPA observed a fully charged fire extinguisher in the kitchen. Medications were locked above the counter. The stove surface and hood were clean. LPA conducted a medication review at approximately 10:00 a.m. Three (03) out of three (03) resident medication quantities were maintained in the proper amount. A washing machine and dryer were located in the laundry area outside of the kitchen. Both were in working order. Detergents and cleaning supplies were locked above the appliances. LPA observed a patio area in the rear of the facility. The patio contained furniture in good condition and an electric piano. Additional shaded seating was located in the back yard. The garage was locked and contained extra supplies. The living room contained a television, reading material, exercise equipment, and furniture in good repair. A fireplace was appropriately covered and turned off. Medications were locked near the main entrance. The facility has three (03) bedrooms. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All rooms with hospital beds had wheels in the locked position. Bedroom #2 and Bedroom #3 contained beds with full bed rails. At 12:00 p.m. LPA verified that all residents with full bed rails had physician orders for bed rails in their files. The facility has two (02) bathrooms. One (01) bathroom was private to Bedroom #1. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 10:15 a.m. LPA measured the water temperature in Bathroom #1 to be 118.4 degrees Fahrenheit. The administrator called the house telephone at 10:45 a.m. The phone was deemed operational. A complete first aid kit was stored near the kitchen. The emergency exit path was free from obstructions. Auditory alarms at the front and in Bedroom #1 and Bedroom #3 were turned on and functioning. At 12:25 p.m., smoke and carbon monoxide detectors were tested and operational. Detectors functioned simultaneously when tested. At 11:10 a.m. LPA reviewed staff and resident 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 or safety hazards were observed. Exit interview conducted. Copy of report provided.