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

Physical Plant & Environment Safety: The facility is a 7 bedroom and 6-bathroom. The facility is occupying 5 residents and employs 4 staff of which one is the Administrator. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. LPA's noted that all resident bedrooms had required furnishings and bedding by regulations. The facility has smoke and carbon monoxide detectors. Carbon Monoxide and smoke alarms were tested and working properly at time of visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The showers have non-skid mats/flooring. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, 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 facility has telephone and internet service for resident use. The backyard has 2 locked sheds to store extra items, including yard tools.

Operational Requirements: The facility has a current plan of operation on file. 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 03/04/2026. The facility is approved for a capacity of 6 non-Ambulatory and approved for hospice waiver of 6.

Continued on 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. A sampling of files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables all files were complete.

Incidental Medical & Dental: The facility has a medication cabinet in the living room 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). Administrator maintains a record of PRNs provided; and has PRN Authorization documents on file. LPA reviewed all 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, and stored appropriately. Fresh fruit and vegetables were 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 disaster drills quarterly. The fire extinguishers were charged and last inspected on 1/30/25.

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 inaccessible to residents in care. The facility does not have delayed egress. The facility does have 3 hospice residents in care. Hospice services records are kept on file. The facility gates are self-latching and self-closing. The backyard is completely fenced.

Exit interview conducted, citation given and copy of report printed for Administrator.