Routine inspection·May 29, 2025

At approximately 9:05 a.m. on 05/29/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit. LPA later spoke to the licensee over the phone to disclose the reason for the visit. At approximately 9:20 a.m. LPA conducted a file review of staff and resident files. All files were complete and available for audit. The facility was last visited on 04/10/24 for an annual inspection. It is a single story building with three (03) bedrooms, three (03) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for five (05) residents, of which five (05) may be non-ambulatory and one (01) may be bedridden. The facility serves residents with dementia. Surveillance cameras are used in the common area. Approved hospice waivers for five (05). At the main entrance and in the office area, LPA observed postings for confidential complaint contacts, emergency disaster plan, emergency contacts, Ombudsman contacts, house rules, visiting hours, personal rights, rights of resident councils, rights of family councils, staff list, resident list, facility sketch with evacuation routes clearly labelled, facility license, and theft and loss policy. Walls, floors, windows, screens, and blinds were clean and in good repair. Extra linens were located in a storage area near Bedroom #2. At 10:40 a.m. LPA measured the room temperature to be 77 degrees Fahrenheit. Two (02) residents were observed watching television in the common area. One (01) resident was coloring at the dining table. Staff was observed preparing food and assisting residents. LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator, freezer and pantry. The stove hood was clean. Appliances were in good condition. At 10:50 a.m. LPA measured the refrigerator and freezer temperatures to be forty (40) degrees and zero (00) degrees Fahrenheit, respectively. Sharps were locked below the counter top. Cleaning solutions were locked below the sink. Medications and a complete first aid kit were locked near the refrigerator. At approximately 11:00 a.m., LPA and staff conducted a medication review. All medications were maintained in the correct quantities. The medication administration record was accurate and current. LPA observed a covered patio areas in the front and rear of the facility. Patios contained furniture in good condition. Ramps leading up to the main entrance, out the back door, and out Bedroom #3 were secure. The back yard also had a grill and maintained gardened areas. Two (02) out of two (02) emergency exit paths were free from obstructions. Two (02) out of two (02) exit gates were unlocked with an inward facing, self-closing latches. A washing machine and dryer were located in the locked garage. Both were in working order. Detergents were located by the appliances. Extra incontinence and hygiene supplies were also in the garage. Five (05) out of five (05) auditory alarms were turned on and functioning. At approximately 11:15 a.m. the dual-functioning smoke and carbon monoxide detector was tested and operational. At approximately 11:20 a.m. LPA observed a fully charged fire extinguisher near the office area. At approximately 11:25 a.m. LPA called the house telephone which was deemed operational. The facility has three (03) bedrooms. All bedrooms contained a lamp, chair, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All hospital beds had wheels in the locked position. The facility has three (03) bathrooms. Two (02) bathrooms are private, and one (01) is shared. All bathrooms contained liquid soap, paper towels, trash can with a tight-fitting lid. The shared bathroom and the private bathroom in Bedroom #2 contained grab bars and non-skid mats in the shower. At approximately 11:35 a.m. LPA measured the water temperature in the bathroom private to Bedroom #2 to be 106.0 degrees Fahrenheit. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.