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 4 bedroom and 2 bathrooms, with one staff room in the garage. The facility is occupying 3 residents and employs 9 staff of which one is the Administrator and one is a back-up administrator. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. 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. The showers have non-skid mats. 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.

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 09/21/25. The facility is approved for a capacity of 6 bedridden and approved for hospice waiver of 4.

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. Three (3) 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. The facility does not handle cash resources.

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 in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA inspected medication cabinet for all prescription and PRN medications. 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. Kitchen areas are kept clean and free of insects and pests.

Disaster Preparedness: The current emergency disaster forms were reviewed. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected in 2025. 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 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 residents currently on Home Health services. The facility has 1 resident on hospice. Hospice services records are kept on file. 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.