Routine inspection·January 28, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Marvia Brown, caregiver, who contacted Nicoleta Hegseth, Administrator, who arrived at 2:55 pm. LPA observed (2) residents in the common area and (2) residents in their rooms at the start of the inspection. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (3). Currently, there is (1) resident on hospice. LPA and the Administrator toured the interior and exterior of the facility including the common areas, (2) private resident bedrooms, (2) shared resident bedrooms with a bathrooms each, (1) separate bath with a walk-in shower, kitchen, staff room, locked laundry area and garage. LPA observed the facility to be clean, in good repair and odor-free, and the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. LPA observed sufficient 2+day perishable, including much fresh produce, and 7+day non-perishable supply of food. Sharps, daily medications and toxins are locked in the kitchen. Medications are also secured in a separate cabinet in the laundry room. LPA observed sufficient linens/blankets/incontinent supplies, PPE, and a complete First Aid kit. The inside temperature was 74*F. Hot water temperature measured 110*F in the kitchen and 118*F in a resident bathroom. Fire extinguisher last serviced 9/20/24. Quarterly fire drills conducted -last drill 1/15/25 with staff and residents. Facility to be sure to conduct a drill on each shift at least quarterly. Smoke/monoxide alarms working. There is a large backyard area and patio with covered seating and an unlocked gate. All required postings are posted. Activities are on hand.LPA reviewed (2) resident files and (2) staff files. Files were found to be complete and contain current paperwork. Medications were reviewed for (1) resident- orders match medications and all documentation is current, including for PRN medications. Staff is completing the required initial/ongoing training and has current First/Aid CPR certifications. RCFE Certificate #6058750740- (exp 2/15/25) is pending renewal. An updated copy of LIC308 and LIC500 to be sent to LPA. Dementia Care Plan in the process of being updated to reflect new regulations effec 1/1/25. Updated land line and email obtained. There were no deficiencies observed. Exit interview. Copy of report provided to Administrator.