Routine inspection·October 31, 2025

Licensing Program Analyst, LPA, Noel Wolf Petersen and Licensing Program Manager, LPM, Liza King arrived unannounced at 10:45am to conduct an annual inspection. Pedrose Home Care, is a 6 capacity facility for 5 nonamb and 1 bedridden. There is 3 resident on hospice, 2 residents who are bedridden and 3 residents with dementia. Facility is observed to have 2 bedridden clients, operating outside the license and beyond the buildings fire clearance, citations issued on following d-page. Physical Plant inspection was conducted including but not limited to kitchen, common areas, bedrooms, bathrooms, storage areas, staff room, exteriors, and evacuation routes. facilility is clean and traffic areas are unobstructed and well lit. Kitchen, has adequate food supply 2 days perishable, 7 days non perishable. Sharps, Medications, are stored locked. common areas and exterior have space for activities and free of trip hazards. Evacuation route gate is in good repair, swings freely and latches closed. bathrooms have functioning hardware, water is delivered within range 105-120*F. Bedrooms have required furniture and furnishings, mattresses are have rubber encasements. Continued on c Page. Smoke/Co alarm was functional, Fire extinguisher was dated 6/9/25, first aid kit is complete. air temp is 69*f. 4 of 4 client files are not up to date, 2 of 3 hospice care plans not present, however interview with administration showed not familiar with hospice care plans. 4 of 4 needs and services care plans were not individualized and/or present. citation issued on following d-page. 3 of 5 Staff files contain up to date cpr/ first aid, finger printing, guardian association, and initial training. partial continuing training 12/20 hours completed for the year 2025. Administrator was advised hospice can provide free additional training(medication administration/documentation) specific to dementia/hospice care. citation was given on following d-page. Clients have no P+I. Safeguarded property forms are not filled out for all clients, Technical violation was issued. 2 staff was interviewed, 2 clients were interviewed. Medication and mars were reviewed for 2 clients at random: there are no start dates on medications, mars are not up to date with the administrated medications for the past 3 days, the prn/refusal documentation does not have required information, the disposal documentation exists but doesn't apply to any residents currently in the facility who have had medications discontinued. LPA gave guidance that the administrator should assert a role of care giving with the clients at a level where they can call the doctors of the clients directly in the event that changes in care need to be responded to. One client has medications stored outside their original containers. Citations were given on following d-page. Administrator files were reviewed: fire drill record doesn't exist, liability insurance is up to date, no need for surety bond, refund and theft and loss policy exists in the plan of operation, property control exists via grant deed, 308 does not designate a person, secretary of state is expired. Citation issued on following d page. LPA is requesting an updated 200(for 2 bedridden), facility sketch(for 2 bedridden), 308(designating a substitute administrator), and a copy of up to date workers comp insurance, filings with secretary of state, safeguarded property for all clients. LPA is giving guidance that an outside agency should give the training for medication documentation and administration. Copy of the report was read and given to the administrator. exit interview was conducted. citations were given as part of this visit. appeal rights were provided. TSP refferal was offered.