Routine inspection·September 26, 2025

At approximately 12:30 p.m. on 09/26/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and disclosed the reason for the visit. The facility was last visited on 07/31/2024 for an annual inspection. It is a single story building with six (06) bedrooms, four (04) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) residents, of which four (04) may be ambulatory and two (02) may be non-ambulatory with one (01) bedridden in Bedroom #5. Approved hospice waivers for three (03). At the main entrance, LPA observed a maintained front yard. Postings for resident rights, confidential complaint contacts, ombudsman contacts, facility sketch, and license were observed near the front. A binder contained additional required postings. A screening station contained hand sanitizer, masks, and a visitor log. The facility has six (06) bedrooms. One (01) bedroom is designated as a staff room. The staff room was free of hazards. Bedrooms contained beds with adequate bedding, chairs, nightstands, night lights, and sufficient storage space. All furnishings were clean and in good condition. Beds had wheels in the locked position. The facility has four (04) bathrooms. Bathrooms contained liquid soap, paper towels or personal towels, trash can, grab bars near the toilet and shower, commodes, shower chairs, and a non-skid surface in the shower. At approximately 12:45 p.m. LPA measured the water temperature to be 108 degrees Fahrenheit in the front bathroom. A hallway closet contained adequate amounts of fresh linens and hygiene supplies. At approximately 12:50 p.m., the room temperature was measured to be 72 degrees Fahrenheit. LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator. At 1:10 p.m. the refrigerator and freezer temperatures were measured to be 35 and -2 degrees Fahrenheit, respectively. The stove hood was clean. Appliances were new and in good condition. Sharps, cleaning solutions, and a complete first aid kit were locked below the counter. Medications were locked above the counter top. At approximately 1:15 p.m. LPA observed a fully charged fire extinguisher in the kitchen with a receipt attached. A washing machine and dryer were located near the kitchen. Both were in working order. Detergents were locked in the laundry room with the appliances. Walls, floors, windows, screens, and blinds were clean and in good repair. LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition. The ramp leading out from the bedridden room was free of hazards and had secure handrails. The emergency exit path was free from obstructions. The exit gate was unlocked with self-closing latches. Evacuation routes were posted. At approximately 2:45 p.m., smoke and carbon monoxide detectors were tested and operational. At approximately 1:30 p.m., LPA conducted a record review of resident and personnel files. Staff files were incomplete and not all available for audit. A deficiency are issued for the licensee not maintaining complete records for all staff. Additionally, a review of Guardian at approximately 2:00 p.m. revealed that only the licensee and administrator were associated to the facility. The administrator noted that all staff have fingerprints and background checks, but most staff files were at the agency. The staff present was not associated to the facility and had worked for about one month. An additional deficiency is issued today along with a civil penalty of $500 for staff present in the facility without an association to the facility. Exit interview conducted. Appeal rights discussed. Copy of report provided.