Routine inspection·January 31, 2025

At approximately 10:45 a.m. on 01/31/2025, 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 12/28/2023 for a prelicensing inspection. It is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen, laundry room, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which one (01) may be bedridden in Bedroom #4. Approved hospice waivers for six (06). LPA observed a maintained front yard upon arrival. The entry gate was unlocked. The main pathway was free of debris and the ramp was secure. A screening station at the front contained surgical masks, N95 masks, sanitizer, a digital thermometer, and a visitor log. Postings at the front included facility license, confidential complaints contacts, ombudsman contacts, emergency disaster plan, rights of resident councils, personal rights, theft and loss policy, and the facility sketch. Walls, floors, windows, screens, and blinds were clean and in good repair. The living room contained furniture in good repair, a television, board games, puzzles, and exercise equipment. At 11:10 a.m. LPA observed a fully charged fire extinguisher near the kitchen. It was last inspected on 01/14/2025 with a tag attached. At 11:15 a.m. LPA measured the room temperature to be 70 degrees Fahrenheit. Night lights were observed throughout the hallways. The facility has four (04) bedrooms. All bedrooms contained a chair, lamp, nightstand, storage, 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. Bedrooms with residents using oxygen had designated signs posted on their doors. The facility has two (02) shared bathrooms. Both bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 11:30 a.m. LPA measured the water temperature in the bathroom near Bedroom #4 to be 109.2 degrees Fahrenheit. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen pantry, refrigerator, freezer, and the extra refrigerator in the garage. Appliances were in good condition. Sharps and medications were locked below the counter top. A locked refrigerator on the counter contained medications. The stove surface and hood were clean. A washing machine and dryer were located in the laundry area along with an adequate supply of fresh linens. Both were in working order. Detergents and cleaning supplies were locked near the appliances. A complete first aid kit was also locked and hung on the laundry room wall. The garage was locked and contained extra supplies. LPA observed a patio area in the rear of the facility. The patio contained a shaded area and furniture in good condition. Pathways were free from obstructions. All emergency exit paths were free of hazards. Four (04) out of four (04) auditory alarms were turned on and functioning. Fire sprinklers were located throughout the facility. At approximately 12:10 p.m., smoke and carbon monoxide detectors were tested and operational. Detectors were hard-wired and functioned simultaneously. At approximately 12:15 p.m. LPA reviewed staff and resident files. All files were complete and available for audit. LPA called the house telephone at 1:00 p.m. The phone was deemed operational. 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.