Routine inspection·February 24, 2025

At 09:20am on 02/24/2025, Licensing Program Analysts (LPA) Mark Jeffries and Garrett Haner-Tomasko arrived at the facility to conduct an unannounced annual inspection. LPAs met with Licensee Susan Marsh. Announced who they are and the reason for the visit being the facility annual inspection. LPAs toured facility with Licensee. The facility has 3 single occupancy and 1 double occupancy bedrooms and 3 bathrooms. The facility is maintained in conformance with state fire marshal regulations. Smoke detectors are functioning throughout the facility. Fire extinguisher is fully charged and serviced this month. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. The facility temperature was 71 degrees F. Water temperatures were noted to be within 105-120 (f). Residents’ rooms are appropriately furnished with adequate lighting. LPA observed more than two days of perishable and more than seven days of non-perishable food. An Emergency and Disaster Plan and Personal Rights are available and located on the facility kitchen wall. Staff files reviewed. LPA's reviewed Emergency Disaster Plan and Infection Control Plan. LPA reviewed medications. Medications are stored in a locked cabinet in the dining room and refrigerator locked in the bedroom closet. During tour of the facility the carbon monoxide detector was noted to be non-functioning, the bath/shower in the hallway bathroom was non-functioning with the water outlet to the tub plugged, and nails were noted to be sticking out of the outside ramp on the west side of the facility, While observing food in the kitchen refrigerator moldy vegetables and an uncovered bowel of cauliflower were cited on the annual care tool. Exit interview, report read, citations issues, appeal rights report provided..