Routine inspection·February 7, 2025

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with the Executive Director Sheila Fike and explained the reason for the visit. The Executive Director's Administrator's Certificate expires on July 17, 2025. The facility is licensed for 96 non-ambulatory residents with a hospice waiver for 20. Facility is a single story building with a central courtyard. LPA and the Executive Director and the Director of Health Services toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entrance of the facility. LPA observed the central courtyard has a covered patio with tables and chairs to sit outside. There is a circular path for walking and a gazebo There is one small raised fountain in the courtyard. No obstacles or hazards observed in the courtyard. The facility is approved for delayed egress. LPA tested the delayed egress doors. The delayed egress doors are operational. LPA observed fire extinguishers throughout the facility. All fire extinguishers are fully charged. The last emergency drill was conducted on November 13, 2024. LPA toured 10 resident rooms. LPA observed all the resident rooms had the required bed linens and furnishings. Hot water measured 111.3 to 120.5 degrees Fahrenheit. LPA observed medication is kept locked in the medication cart stored in the medication room. LPA inspected the first aid kit. The first aid kit did not contain a current edition first aid manual. LPA observed both (2) medication carts were locked. LPA observed all cleaning supplies are kept locked in a storage room. LPA observed the kitchen is clean and organized. LPA observed a 2 perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed a 3 day supply of emergency food and water in the kitchen. LPA observed lunch being prepared in the kitchen and lunch being served in the dining room. LPA observed residents participating in an arts and crafts. No obstacles or hazards in the facility. LPA observed an activity room with games and a TV. LPA reviewed 10 resident files and medications. No discrepancies observed. LPA reviewed 7 staff files, no discrepancies observed. Staff had the required training. All staff All staff observed at the facility are background cleared and associated to the facility. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.