Routine inspection·May 1, 2024

At 10:45 a.m. on 05/01/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit. LPA and staff toured the facility inside and out at 10:50 a.m. The facility was last visited on 04/19/2023 for a prelicensing visit. It is a single story building with seven (07) bedrooms, four (04) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for 6 nonambulatory residents, of which one (01) may be bedridden in Bedroom #5 or #6. The facility serves residents with dementia. Approved hospice waivers for six (06). The front yard was well maintained and contained a fountain, a carport, and ramps in good condition leading to the front door. At the main entrance, LPA observed postings for COVID precautions, visitation policy, confidential complaint contacts, Ombudsman contacts, facility license, administrator certificate, house rules, personal rights, rights of resident councils, emergency disaster plan, theft and loss policy, activity schedule, and the lists of staff and residents. A sign was hung stating “No smoking – Oxygen in use”. At approximately 10:55 a.m. LPA observed a fully charged fire extinguisher in the kitchen. At 11:00 a.m. LPA called the house telephone and confirmed it to be operational. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter top. Medications and confidential files were locked near the dishwasher. A washing machine and dryer were located in a laundry area adjacent to the kitchen. Both were in working order. Detergents and cleaning solutions were locked above the appliances. The staff room was locked and located past the laundry room. The facility has six (06) other private bedrooms for residents. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Bathrooms: The facility has four (04) bathrooms. All bathrooms contained liquid soap, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. Staff stated residents use their personal hand towels to dry their hands. At approximately 11:10 a.m. LPA measured the water temperatures in the bathrooms near the staff room and the bathroom in Bedroom #5 to be 137.0 degrees Fahrenheit and 134.5 degrees Fahrenheit. This deficiency is cited on the LIC 809-D page. Walls, floors, windows, screens, and blinds were clean and in good repair. A resident was observed watching television in the living room. The living room contained exercise equipment, reading material, an appropriately covered fireplace, and furniture in good repair. A linen closet in the hallway contained an adequate supply of fresh linens. At 11:20 a.m. LPA measured the room temperature to be 71 degrees Fahrenheit. LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition as well as two rabbits and a dove. Hand rails were secure. The back yard contained a gardened area. All emergency exit paths were free from obstructions. Three (03) out of three (03) exit gates were unlocked with self-closing latches. Evacuation routes were posted. Auditory alarms were turned on and functioning. Fire sprinklers were observed throughout the house. At approximately 11:30 a.m., smoke and carbon monoxide detectors were tested and operational. LPA conducted a record review of staff and resident files at 11:45 a.m. At approximately 12:45 p.m. LPA observed two (02) out of two (02) staff CPR/First Aid certifications were not present. This deficiency is cited on the LIC 809-D page. Exit interview conducted. Appeal Rights discussed. Copy of report provided.