Routine inspection·February 20, 2025

At approximately 10:45 a.m. on 02/20/2025, 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 12/18/2023 for an annual visit. It is a single story building with seven (07) bedrooms, seven (07) bathrooms, kitchen, laundry room, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents. Approved hospice waivers for six (06). LPA observed a maintained front yard. A screening station at the front contained sanitizer, masks, and a visitor log. Postings at the front and in the main hallway included COVID precautions facility license, confidential complaints contacts, ombudsman contacts, neighborhood complaint procedures, theft and loss policy, facility sketch with evacuation routes clearly labelled, emergency disaster plan, non-discrimination notice, a blank copy of the admission agreement, rights of resident councils, and personal rights. Walls, floors, windows, screens, and blinds were clean and in good repair. At 11:15 a.m. LPA measured the room temperature to be 70 degrees Fahrenheit. The living room contained a television, reading material, games, exercise equipment, and furniture in good repair. A fireplace was turned off and appropriately covered. Resident artwork was hung in the dining area. An office near the front entrance was locked and contained an additional refrigerator, confidential files, and extra supplies. Medications were inaccessible in a separate closet near the office. An additional activity area near the middle of the facility contained music supplies, exercise equipment, and reading materials. The facility has seven (07) bedrooms. One (01) bedroom is designated as a staff room. The staff room was unlocked and free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, bed alarms, call systems, and a bed with adequate bedding. All furnishings were clean and in good condition. All rooms had hospital beds with wheels in the locked position. The facility has seven (07) bathrooms. Each bedroom has a private bathroom in addition to the staff bathroom. All resident bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, and grab bars near the toilet and shower or commodes with grab bars. At approximately 11:50 a.m. LPA measured the water temperature in the private bathroom to Bedroom #2 be 119.3 degrees Fahrenheit. LPA called the house telephone at 12:15 a.m. The phone was deemed operational. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. Appliances were in good condition. Sharps were locked under the counter top. At 12:20 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 07/17/24. The laundry area was adjacent to the kitchen. It was locked and contained a washing machine, a dryer, and chemicals. Both appliances were in working order. LPA observed a shaded patio area in the rear of the facility along with sufficient space for activities. The patio contained furniture in good condition. The emergency exit path was free from obstructions. The exit gate was unlocked. Two (02) out of two (02) auditory alarms were turned on and functioning. At approximately 12:30 p.m., smoke and carbon monoxide detectors were tested and operational. Detectors were hard-wired and operated simultaneously. The hallway fire door closed automatically when tested. 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.