Routine inspection·June 26, 2025

At approximately 9:15 a.m. on 06/26/25, 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 05/01/24 for an annual inspection. 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 non-ambulatory residents, of which one (01) may be bedridden in Bedroom #5 or #6. Approved hospice waivers for six (06). The front yard was maintained and contained a carport and ramps in good condition. At the main entrance, LPA observed postings for COVID precautions, a blank copy of the admission agreement, 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”. The facility has seven (07) bedrooms. One (01) bedroom near the laundry area served as a staff room. The staff room was attended and free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Both residents were observed relaxing in their rooms during the inspection. Walls, floors, windows, screens, and blinds were clean and in good repair. The living room contained exercise equipment, reading material, board games, art supplies, an appropriately covered fireplace, and furniture in good repair. A linen closet in the hallway contained an adequate supply of fresh linens. At approximately 9:30 a.m. LPA measured the room temperature to be 75 degrees Fahrenheit. At approximately 9:45 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 04/23/25. At 10:00 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. A weekly menu was posted on the refrigerator. Appliances were in good condition. Sharps and confidential files were locked below the counter top. Medications were locked above the counter top. Cleaners were locked below the sink. 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 facility has four (04) 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, and a non-skid mat in the shower. At approximately 10:10 a.m. LPA measured the water temperature in the bathroom near Bedroom #1 to be 109.9 degrees Fahrenheit. LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition as well as small animals in cages. Hand rails were secure. The back yard contained a large gardened area and a locked storage shed with tools inside. 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. Fire sprinklers were observed throughout the house. At approximately 10:30 a.m., smoke and carbon monoxide detectors were tested and operational. At approximately 10:45 a.m., LPA and staff conducted a medication review. Resident medication counts accurately matched the amounts prescribed and documented. LPA conducted a record review of personnel and resident files at 11:00 a.m. All files were complete and available for audit. During today’s inspection, the facility is in compliance with Title 22 regulations. No immediate health or safety concerns were observed. Exit interview conducted. Copy of report provided.