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 4 bedrooms and 3 bathrooms. The facility occupies 4 residents and employs 5 full-time staff of which one is the Administrator and one is a back-up administrator, with 4 relief staff. The facility is clean, safe and sanitary. The facility has smoke and carbon monoxide detectors which were tested and working properly at time of inspection. The lighting and lamps are sufficient for the use of the facility and for resident comfort and safety. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secure 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 facility has telephone and internet service for residents’ use.

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 09/21/26.

Staffing, Personnel Records & Training: LPA reviewed staff files. Files were reviewed for, but not limited to current 1st Aid/CPR, Personnel Records/Application, and Health screening with TB results. Administrator Certificate expires on 10/27/27. All files were kept up to date with all requirements being met. LPA reviewed staff training records for Annual Training Requirements of 20 plus hours and 8 hours of Medication training.

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.

Incidental Medical & Dental: The facility has a medication cabinet 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 in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). 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. Kitchen areas are kept clean.

Disaster Preparedness: The current emergency disaster forms were reviewed. The facility conducts quarterly disaster drills. The fire extinguishers were charged last inspected in 2/18/26. 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 such as sharps, and cleaners were inaccessible to residents in care. The facility does not have delayed egress. The facility does not currently have residents with oxygen. The facility has 1 resident currently on Home Health services. The facility has 1 resident on hospice. The facility gate is self-latching and has self-closing equipment on one side. The backyard is completely fenced. The facility has exiting door alarms, which were working on LPA's visit.

Exit interview conducted and copy of report printed for Administrator.