A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Physical Plant & Environment Safety: The facility has 5 resident bedrooms, 2 bathrooms and currently occupies 3 residents. The facility has smoke and carbon monoxide detectors that were tested and working properly during visit. 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 secure grab bars are present. The showers have non-skid mats or textured bottoms. A schedule for resident’s showers was posted on the refrigerator door. All residents require assistance in bathing so a plan to ensure all residents receive their showers is tracked. The pathways are clear of any obstructions. Disinfectants, cleaning solutions and poisons are inaccessible to residents in care locked under sink and in the garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard with gates on both sides of the home. The facility has telephone and internet service for resident use.

Operational Requirements: The facility has a current plan of operation on file with the department. The facility has current liability insurance and expires on 01/07/27. The facility is approved for a capacity of six. The fire clearance is granted for 6 non-Ambulatory of which 4 may be bedridden. Hospice is approved for 4. There are currently 3 residents.

Continued 809-C

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training on various topics noted in their records. Training for 2025 was documented.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidential. LPA reviewed four resident files for signed Admission Agreements, Physician Reports, Annual Needs and Services Plans, and other required documents and found all required documents. In addition, LPA reviewed prior resident file to ensure Hospice paperwork and medication was documented as required.

Medication Review: LPA conducted a medication review. Medication was documented on a Centrally Stored Medication Record as well as tracked on Medication Administration Records. All medication and records were found to be updated and in compliance with regulations.

Food Service: The facility has 2-day perishables and 7-day non-perishables to meet the food service requirements. Kitchen was clean, safe and sanitary. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen staff are observed for personal hygiene and food sanitation practices. At time of visit LPA observed individual meals being prepared for residents as they were ready for their meals.

Disaster Preparedness: The current emergency disaster forms were posted. Emergency exits and telephone numbers were posted. Drills are conducted quarterly. 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. The facility currently has residents receiving Hospice services. Facility has a planned activities schedule on the refrigerator door with various activities scheduled to engage residents. Exit door alarms are working.

Exit interview conducted, copy of report, issued.