KITCHEN: Kitchen appliances appeared to be in operable condition. At 9:45 A.M. hot water measured at 111.8 degrees. Cleaning supplies were stored in a locked cabinet under the kitchen sink. The facility has a sufficient supply of perishable and non-perishable food. At 9:57 A.M., LPA conducted a review of expiration dates on product labels. The LPA observed that three (3) items were past their expiration date. Back-up Administrator discarded all three (3) items during today’s visit. Technical Advice Issued.

Continued on LIC 809-C

BEDROOMS: There are 5 (five) bedrooms total, of which 2 (two) are private rooms, 2 (two) are designated for shared resident use and 1 (one) is a staff room. All bedrooms observed were furnished and contained beds, chairs, bedside tables and lamps. All beds have appropriate linens.

BATHROOMS: The facility has 2 (two) bathrooms, 1 (one) is designated for shared resident use and 1 (one) for private resident use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. Between 10:08 A.M. and 11:18 A.M. hot water temperature was measured and measured within the required range.

LAUNDRY ROOM: LPA observed laundry room to be locked. Cleaning supplies and hygiene products were observed to be locked in a hallway cabinet and properly stored at the time of the visit.

GARAGE: The garage is attached to the house. Garage was observed to contained extra mobility aid supplies, decoration, cleaning supplies and storage. Emergency water was observed in the garage.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. However, Long-Term Care Ombudsman poster was covered by Community Licensing forms. The LPA requested that the Administrator remove these forms and ensure that the poster remains free of obstructions at all times. Technical Advice issued. A fireplace was observed to be inaccessible to residents in care. The facility maintained a comfortable temperature of 69 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed.

Continued on LIC 809-C

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. All exits and passageways were observed to be free of hazards. There were no bodies of water noted. Facility has one side gate. LPA observed side gate to be self-latching and closing with clear passageways for emergency exit use.

RECORD REVIEW: Between 11:19 A.M. and 12:27 P.M., Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Three (3) resident records reviewed were complete and contained all required documents. Five (5) staff files including Administrators were reviewed. LPA observed that Staff #1 (S1) and Staff #2 (S2) were hired in 08/2024 but are not CPR training was not complete. Additionally, LPA observed missing ID form (LIC 501), Job application, Health Screening form (LIC 503) and Criminal Record Form (LIC 508) for S1. During today's visit S1 completed LIC 508, LIC 501.

MEDICATION REVIEW: At 12:42 P.M. LPA started medication review. Medications for three (3) residents were observed. Medications are centrally stored and locked in a hallway cabinet. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. residents' medications are maintained and administered in compliance with regulation.

Continued on LIC 809-C

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.