Routine inspection·April 24, 2026

Licensing Program Analyst (LPA) De Leon arrived at 10:15am to conducted a 1 year annual visit to the facility above. LPA met with back up to Administrator Robert Budai and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Infection Control Plan. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Facility staff need to be trained upon hire and annually thereafter on infection control and plan. Physical Plant & Environment Safety: The facility is a 5 bedroom with 2 on suite bathrooms and 1 main restroom for residents, staff and visitors. The facility currently occupies 4 residents, and is staffed with 4 staff and 2 administrators. The facility is clean, safe and sanitary. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The gates are self-closing and self-latching. The facility has outdoor furniture for residents use with shaded area. Laundry room has working washer and dryer. Water was tested in the main restroom measured at 152.2 F, Administrator turned down water heater and LPA at end of visit tested and measured at 143.6, Administrator adjusted the water heater and will check temperature again and adjust if needed. Operational Requirements: The Facility is operating in compliance with fire clearance. The facility provided current liability insurance valid till 06/15/2026. The fire clearance is granted for 6 non-ambulatory, of which 1 may be bedridden. Hospice wavier granted for 4. Continued 809-C Staffing: The facility employes 4 staff and 2 Administrators. Staff records are kept confidential. Staff records were reviewed for 4 staff and 2 Administrators. 2 out of 6 records had fingerprint clearance and associations with criminal record statements, personnel record or application, First Aid and CPR certificates and Health screening with TB results. All records had fingerprint clearances, 1st Aid and CPR. Administrator file was reviewed for continuing education which was not available for review. Administrator Certificate expired 04/18/2026 and other administrator certificate was verified on CCL pending list. Personnel Records & Training: The facility keeps confidential binder with taps for each staff member. Files lacked training hours and subjects for 2025-2026 for 20 hours. Some staff had training records but did not met the required hours and new staff files need 40 hours of initial training. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four Files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Files were current and up to date. Resident Rights Information: All require postings were posted in common areas of facility. Personal rights, Theft and Loss policy, Nondiscrimination notice, CCL Complaint poster is posted on entry and LTCO poster is posted in the dining room. Planned Activities: The facility offers activities to all residents in care. Activities include books, magazines, newspapers, TV watching, daily walks, group discussions and communications, and puzzles. The facility has sufficient space to allow for activities indoors and outdoors. Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available in the garage. Incidental Medical & Dental: Facility provides transportation or assist in providing transportation to medical and dental appointments when needed. The medications records were reviewed for all 4 residents in care. Each Residents has a Medication Administration Records (MAR) and the Centrally Stored Medication and Destruct Records (CSMDR). LPA completed a full audit of residents medication, all medications were stored in the original containers, prescription labels were not altered, and no medications were expired. Doctors orders were present in resident files. Continued 809-C Disaster Preparedness: The current emergency disaster forms were posted. The facility did not have disaster drills quarterly for 2026 year. The fire extinguishers were charged. The dual smoke and carbon monoxide detectors are present and hard wired throughout the facility. The facility has disaster supplies present with extra food and water. Residents with Special Health Needs : The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked separately in cupboards. The facility does have 1 hospice residents in care, care plan is up to date and present. The facility does have one Home Health resident in care, home health plan is present and kept up to date. The facility does not have any current residents on oxygen. The facility has exiting door alarms, tested and working properly. The facility does not have delayed egress, secured perimeters with locked gates or doors. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator.