Routine inspection·August 20, 2025

At approximately 9:30 a.m. on 08/20/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit. The facility was last visited on 07/02/2024 for a prelicensing inspection. It is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen, garage, laundry room, common areas, outdoor space, and a pool. It has an approved fire clearance for six (06) residents, of which five (05) can be non-ambulatory and one (01) bedridden resident in bedroom #1. Approved hospice waivers for (06) residents. LPA entered through an unlocked door with a keypad. At the main entrance, LPA observed postings including but not limited to the facility’s nondiscrimination notice, theft and loss policy, personal rights, rights of resident councils, emergency disaster plan, and contacts for the Ombudsman and confidential complaints. At approximately 9:45 a.m. LPA measured the room temperature to be 77 degrees Fahrenheit. Cameras were observed on the exterior of the facility. Walls, floors, windows, screens, and blinds were clean and in good repair. The living room contained furniture in good repair, an appropriately covered fireplace, and reading materials. Puzzles, art supplies, and exercise equipment were stored in a hallway closet. The facility had four (04) bedrooms. All bedrooms contained a nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. At approximately 10:10 a.m. LPA observed the resident in Bedroom #2 with full bed rails. Interview with the administrator at approximately 10:45 a.m. revealed the resident is not receiving hospice services. A deficiency is issued on the corresponding LIC 809-D page for the retaining a resident with full bed rails without hospice services. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen refrigerator, freezer, and pantry. The garage was locked and inaccessible. At 10:25 a.m. LPA measured the refrigerator and freezer temperatures to be 40 and -3 degrees Fahrenheit, respectively. The stove hood and surface were clean. Appliances were in good condition. Sharps were locked under a counter. Medications were locked above the counter in a cabinet. Cleaning solutions were locked in the laundry area along with a fully-stocked first aid kit and a washing machine and dryer. At approximately 10:30 a.m. LPA observed a fully charged fire extinguisher in the kitchen. All emergency exit paths were free from obstructions. The exit gate was unlocked with a self-closing latch. At approximately 10:40 a.m. the dual-purpose smoke and carbon monoxide detector was tested and operational. Facility detectors are hard-wired and functioned simultaneously during the test. The fire door near the main entrance closed during the test as well. Three (03) out of three (03) auditory alarms were tested and functioning. The house telephone was called at 11:00 a.m. and deemed operational. The facility had two (02) bathrooms. Bathrooms contained liquid soap, paper towels, a trash can with a tight fitting lid, grab bars in the shower, and a non-skid mat in the shower. The toilet in Bathroom #1 did not have grab bars. A deficiency is issued on the corresponding LIC 809-D page for the lack of grab bars. At 12:40 p.m. LPA measured the water temperature in Bathroom #1 to be 114.0 degrees Fahrenheit. LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition and exercise equipment. The ramp which led out was secure. The pool was gated and locked to be inaccessible. A storage shed was locked and contained decorations. Around 11:30 a.m. LPA reviewed resident and personnel files. All resident and staff files were available but incomplete. Deficiencies are issued on the corresponding LIC 809-D for incomplete staff and resident files. Exit interview conducted. Appeal rights discussed. Copy of report provided.