Routine inspection·July 17, 2025

Licensing Program Analyst (LPA) De Leon arrived at 11:00 am to conducted a 1 year annual visit to the facility above. LPA met Administrator Rebecca Michel and explained the purpose of the visit. A tour of the inside and outside of the facility with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted an Infection Control Plan. The facility has a sign in and out clipboard for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE) initially upon hire and annually thereafter. Physical Plant & Environment Safety: The facility has 14 bedrooms (1 shared room), 4 bathrooms, and 1 shower room for resident use currently occupying 15 residents. 1 common area restroom designated for staff and visitors. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke detectors which are hard wired. The facility has a sprinkler system. The facility has 3 carbon monoxide detectors. The facility has the fire system inspected annually and administrator provided the current report. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. Non-slip mats and textured bottoms on the shower floors are present. All pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in laundry room. The laundry room has a working washer and dryer. The facility has sufficient space inside and outside for activities and visiting. The facility has a courtyard for resident use with an umbrella for shade and self-closing, self-latching coded delayed egress gate to exit. The facility has 5 doors with delayed egress. The facility has telephone and internet service for resident use. The facility has three sitting areas throughout the facility for resident use. Continued 809-C Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 09/02/2025. The facility is approved for a capacity of 15 non-Ambulatory of which all may be bedridden and a Hospice waiver for 8 residents. Staffing: Facility employees 19 staff and 1 administrator. Staff records are kept confidential. LPA reviewed 5 staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Personnel Records & Training: Staff training records were reviewed 5 staff training records had 20 plus hours of training for 8/2024-07/2025. Administrator Certificate expires 07/18/2026. Administrators file had all continuing education for Administrator Certificate. Resident Records & Incident Reports: The facility keeps separate files on each resident confidential. Five files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID & Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. The Facility does not handle cash resources for any of the residents in care. Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster is posted in the entryway of the facility and LTCO poster was posted in the common area. Visitation policy is posted at entry. Internet is provided to residents with confidentiality and privacy. 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. All food is covered, stored, and marked appropriately. Food, snacks, and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter and insects. The kitchen has two closing gates at each end of the kitchen to keep dementia residents safe. Incidental Medical Services: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed. The facility uses a form that has the same information as the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). Medications were checked for expiration dates, stored in original containers and no labels were altered. Continued 809-C Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected on 06/27/2025. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency . Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger such as sharps, and cleaners were locked and inaccessible to residents in care. The facility does have delayed egress. The facility does currently have 1 resident with PRN oxygen. The facility has 2 hospice residents in care. Hospice care plans are kept on file and up to date. The facility does not currently have any residents on Home Health services. LPA conducted interviews with 1 Staff and 3 Residents. Exit interview conducted and copy of report printed for Administrator.