Routine inspection·March 20, 2026

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by designee. Facility currently has five (5) residents in care one (1)vof which are currently on hospice. Upon arrival, LPA observed caregiver (S1) present and working in facility but not listed on Guardian roster printed 3/19/26. During LPA inspection of physical plant S1 left the facility. Designee provided LPA with S1's personal information including birthday, driver's license, and last name, but this person turned out not to be the person that was actually presen. Person actually present was staff (S2). S2 name and birthday given to LPA. Per designee, S2 does not have fingerprint clearance. LPA advised S2 cannot return to facility until S2 has fingerprint clearance ( deficiency cited, see 809D ). Licensee is aware that S2 did not have fingerprint clearance as she is the one responsible for hiring staff and associating staff to facility. At approximately 2:40pm LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Box containing 150 eggs left outside of refrigeration inside garage, temperature today was 96 degrees F outside ( deficiency cited, see 809D ) LPA observed refrigerator to not be cool, no temperature reading available but refrigerator was leaking. Garage has two [2] refrigerators and one freezer. Per designee, the other refrigerator has also been leaking and licensee is aware. Light is broken on refrigerator in kitchen. Tile around kitchen sink is in disrepair and showing areas of black and gray substance ( deficiency cited, see 809D ). Cleaning products and laundry soaps are inaccessible to residents in care. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required grab bars but private bath in room #1 did not have mat. Water temperature in sinks measured at 109.2 degrees F in Continued on 809C... Continued from 809... the kitchen and 109.3 degrees F in the bathroom used by residents, both of which are within the allowable range of 105 to 120 degrees F. Facility has another bathroom used by staff only. Fire extinguishers were last inspected 1/14/25, but showing as fully charged. Smoke/Carbon Monoxide detectors tested and operational. During inspection of physical plant LPA observed medication cabinet to be open and unlocked ( deficiency cited, see 809D ). Additionally, LPA observed medications and supplements in staff room, however, room was locked. LPA advised it could be a good practice to keep all prescription medications if not locked, then secured in a drawer or something in the event that the staff room is accidentally left unlocked. Fireplace in dining area needs a screen. LPA spoke to resident (R1) who informed LPA that staff make all the residents go to their rooms between the hours of 1pm and 3pm. R1 informed LPA that they wanted to go outside but was told they had to stay in their room. LPA immediately informed staff that residents have personal rights, one of which is to have to make choices concerning their daily life in the facility ( deficiency cited, see 809D ). LPA observed residents lying in bed staring at the wall or ceiling. LPA advised designee residents need to have activities to participate in and have cognitive stimulation that meets their needs ( deficiency cited, see 809D ). LPA will return at a later date to conduct file review, complete inspection, and issue citations on 809D s for those items noted today as deficiency cited . Exit interview conducted with designee and a copy of this report given.