At approximately 9:00 a.m. on 03/06/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the licensee and administrator and disclosed the reason for the visit.

A file review was conducted prior to the visit. The facility was last visited on 02/28/24 for an annual inspection. It is a single story building with five (05) bedrooms, three (03) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for five (05) nonambulatory residents and one (01) bedridden resident in Bedroom #5. The facility serves residents with dementia. Approved hospice waivers for six (06).

At the main entrance, LPA observed postings for the facility license, facility sketch, administrator certificates, COVID precautions, emergency disaster plan, visitation policy, a blank copy of an admission agreement, nondiscrimination notice, rights of resident councils, personal rights, ombudsman contacts, confidential complaint contacts, and the theft and loss policy. A sign hung on the main entrance and Bedroom #4 to indicate “No Smoking – Oxygen in use”. A screening station at the front contained a mounted digital thermometer, masks, hand sanitizer mounted on the wall, and a visitor’s log.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:20 a.m. LPA measured the room temperature to be 71.0 degrees Fahrenheit. A linen closet in the hallway contained adequate supplies of fresh linens. A locked cupboard contained a complete first aid kit. The main entrance contained a piano, furniture in good repair, and a fireplace which was appropriately covered. Around 9:30 a.m. two (02) staff were observed engaging four (04) residents in exercise in the living room. The living room also had games, puzzles, books, and art supplies. The visitation area was adjacent to the living room and contained adequate space, furniture in good repair, and exercise equipment.

The facility has three (03) bathrooms. Two (02) bathrooms are shared and one (01) is private to Bedroom #3. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 9:40 a.m. LPA measured the water temperature in the private bathroom to be 115.5 degrees Fahrenheit.

LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator, freezer, and pantry. The pantry also contained supplies of emergency food and water. The stove hood was clean. Appliances were in good condition. Allergen and dietary information were posted on the fridge. An activity calendar and emergency contacts were hung in the dining room. Sharps were locked below the counter. Cleaning solutions were locked below the sink. Medications were locked in a file cabinet in the dining area. The call system was routed to the kitchen where staff observed any requests for care. A washing machine and dryer were located in the laundry room near Bedroom #5. Both were in working order. Detergents were locked near the appliances.

LPA observed a patio area in the rear of the facility. The patio contained furniture in good condition. The ramps leading out from Bedroom #3 and from the living room were secure. The garage was locked and contained extra hygiene supplies, assistive devices, and emergency supplies.

All emergency exit paths were free from obstructions. The exit gate was unlocked. Four (04) out of four (04) auditory alarms were turned on and functioning. At approximately 10:00 a.m., the smoke and carbon monoxide detectors were tested and operational. The fire door to Bedroom #5 closed when tested. At approximately 10:15 a.m. LPA observed a fully charged fire extinguisher in the dining room. It was last inspected on 11/08/24.

LPA reviewed resident and personnel files at 10:55 a.m. All files were complete and available for audit.

During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed.

Exit interview conducted. Copy of report provided.