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 is a 6 bedroom and 3 bathroom home. One room is for staff. The facility occupies 4 residents and employs 3 staff of which one is the Administrator and facility has 2 on-call staff. The facility is clean, safe and sanitary. LPA noted that all resident bedrooms had required furnishings and bedding. The facility has smoke and carbon monoxide detectors which were tested and working at time of visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort and safety. The showers have non-skid flooring. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Disinfectants, cleaning solutions and poisons are inaccessible to residents. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with furniture and plenty of shade. The backyard has a locked shed to store extra furniture and items.

Operational Requirements: The Facility is operating in compliance with the granted fire clearance based on the facility sketch. The facility has current liability insurance and expires on 03/07/2027. The facility is approved for a capacity of 6 non-Ambulatory and approved for hospice waiver of 1.

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.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidential. Four files were reviewed for but not limited to signed Admission Agreements, Medical Assessments, ID and Emergency contact forms. Records complete.

Incidental Medical & Dental: The facility has a medication cabinet in the kitchen that is kept locked. Facility provides or assist in providing transportation to medical and dental appointments when needed. The medications records were reviewed, and all residents had a Centrally Stored Medication Destruction Record (CSMDR) and Medication Administration Records (MAR) . Administrator maintains a record of PRNs provided. LPA reviewed a sampling of residents’ medications, no medications labels were altered, no expired medications, and medications were stored in original containers.

Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. All food is covered, stored and marked appropriately. Fresh fruit and vegetables was noted by LPA. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, and insects.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills; last drill occurred in January of 2026. The fire extinguishers were charged and last inspected on 3/2/26. Emergency exits and telephone numbers were posted. 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. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have delayed egress. The backyard has a double gate that needs to be repaired, and the facility is actively working on it.

Exit interview conducted and copy of report printed for Administrator.