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25 | At 11:40 a.m. on 02/20/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit.
A file review was conducted prior to today’s visit.
The facility was last visited on 01/22/26 for a complaint visit. It is a single story building with six (06) bedrooms, four (04) bathrooms, kitchen, laundry room, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which one (01) may be bedridden. Approved hospice waivers for two (02). The facility serves residents with dementia. Four (04) out of four (04) auditory alarms were observed on and functioning
LPA observed a maintained front yard with gardened plants. The front gate was unlocked. A screening station at the front contained surgical masks, sanitizer, a digital thermometer, and a visitor log. Postings at the front and near the office area included COVID precautions, visitation policy, facility license, confidential complaints contacts, ombudsman contacts, emergency disaster plan, rights of resident councils, personal rights, theft and loss policy, and the facility sketch.
Walls, floors, windows, screens, and blinds were clean and in good repair. The living room was clean and had furniture in good repair, board games, art supplies, and reading materials. Hallway closets contained an adequate supply of fresh linens. Another closet was locked and contained cleaning supplies and PPE. The laundry area was locked and contained an operable washer and dryer and detergents. The office area contained locked medications and confidential files. At approximately 12:20 p.m., LPA conducted a medication review for two (02) out of four (04) residents. All medications were stored in the correct quantities.
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