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25 | At 8:35 a.m. on 04/30/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator and disclosed the reason for the visit.
The facility was last visited on 05/03/2022 for an annual inspection. It is a single story building with five (05) bedrooms, three (03) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) residents, of which six (06) may be non-ambulatory. The facility serves residents with dementia. Approved hospice waivers for three (03).
At 8:45 a.m. today, LPA conducted a record review of resident and personnel files. All required files were available for inspection and up to date. After the administrator arrived at 9:35 a.m. LPA and administrator toured the facility inside and out.
The main entrance had two unlocked gates and a courtyard leading to the front door. The front yard had gardened areas, a fountain with no water, and a semicircle driveway. Once inside, LPA observed postings for confidential complaint contacts, Ombudsman contacts, emergency disaster plan, facility sketch and license, rights of resident councils, personal rights, neighborhood complain procedures, and a blank copy of an admission agreement. A sign stating “No smoking – Oxygen in use” was also posted at the front door.
The facility has five (05) bedrooms. One (01) bedroom is designated as a staff room. The staff room was free of hazards. Bedrooms #4 and #1 were shared. Bedrooms #5 and #3 were private. The ramp and handrail in Bedroom #1 were secure. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition.
Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:40 a.m. LPA measured the room temperature to be 70 degrees Fahrenheit. Two (02) residents were observed eating breakfast in the dining room. The dining room contained board games and furniture in good repair. The living room contained reading material, a massage chair, a couch, and a television. Night lights were observed in the hallways.
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