Physical Plant & Environment Safety: LPA toured 5 resident rooms and observed that rooms were tidy, 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 flooring. The pathways are clear of any obstructions. Facility is well lit inside for safety. Disinfectants and cleaning solutions are inaccessible to residents in care and locked in kitchen closet and housekeeping room. The facility has sufficient space inside and outside for activities and visiting. The facility has telephone and internet service for resident use. The fire extinguishers were last charged and inspected on 10/14/25. The facility has carbon monoxide detectors throughout the facility, and a sprinkler system. Sprinkler system was certified tested on 5/19/25.

Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 140. The fire clearance is granted for 140 non-ambulatory of which 10 may be bedridden. Hospice waiver approved for 40 residents. The facility currently has 96 residents. There are currently 4 residents on hospice. Certificate of liability expires 10/1/26.

(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. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians reports, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms. All forms were legible.

Activities: During visit, LPA heard singing, games, a bible study, and toured garden where residents were walking, visiting on the patio, and enjoying pets in the community. Garden area is large, with multiple paths, shaded areas, and plants. It was clean, well maintained, and gated. Copies of the last 5 months’ activity calendars were provided to LPA. Activities noted for date of LPA visit, matched activities that occurred.

Food Service: The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower, logs of temperature checks were reviewed. All food is covered, stored, and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies.

Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents’ medications, no labels were altered, no medications were expired, and all medications were kept in their original containers.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts monthly disaster drill/training, last one was conducted on 10/21/25. 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. During recent fire event facility pre-called family to prepare for possible evacuation.

Exit interview conducted, no deficiencies issues and copy of report printed for Administrator.