BEDROOMS: LPA and the facility staff toured six (6) randomly selected bedrooms; three (3) on the first floor and three (3) on the second floor. All rooms observed were properly furnished with sufficient lighting and clean linens and appropriate furnishings. All client bedrooms were observed to be clean and in good repair.

BATHROOMS: All client rooms have an attached private bathroom. Additionally, there is a staff restroom located in the kitchen. All bathrooms inspected were observed to be clean and in good repair The hot water temperature tested in all inspected bathrooms and was observed to be within the range of 112.6 – 114.0 degrees Fahrenheit which is in compliance with regulation. All inspected grab bars were observed to be appropriately secured.

KITCHEN: LPA observed the kitchen to be inaccessible to clients. The kitchen area appeared to be clean and in good repair. All appliances and fixtures appeared to be functional. LPA observed a sufficient supply of two (2) days perishable and seven (7) days non-perishable food stored in the refrigerators and freezers. The refrigerator and the freezer were observed to be maintained at an appropriate temperature. Knives and other sharp utensils were stored in the kitchen inaccessible to clients in care. CONTINUED ON LIC 809C.

• 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.

STAFF AREAS: This includes the nurse’s station and entry office. LPA observed nurse’s station to be inaccessible to clients in care. LPA observed the entry office to be properly secured. The entry office contained medications and facility files which were stored securely. The facility’s fire alarms and fire doors were last certified on 02/18/2026 and were certified for a period of one (1) year.

OUTDOOR AREAS: LPA observed a covered parking area attached to the side of the facility. LPA observed patio furniture appropriate for outdoor use and adequate space for outdoor activities. LPA observed a front patio area near the facility entrance which was the designated smoking area and was equipped with patio furniture appropriate for outdoor use. LPA observed clear passageways to all emergency exits.

RECORD REVIEW: Record review began at 12:00 PM. Resident records were reviewed for documents including, but not limited to: TB test, resident physician's report, needs and service appraisal, consent forms, and personal rights. Nine (9) resident files were reviewed. All resident files were observed to contain all required documentation and signatures. No deficiencies were observed during record review.

Due to time constraints, LPA will return at a later date to conduct a staff file review, a medication review, a cash resource review, a review of the facility’s infection control plan, a review of the facility’s emergency disaster plan, resident interviews, staff interviews, and to collect copies of facility documents.

No deficiencies were observed during today’s inspection. Exit interview was conducted with the Administrator and copy of the report was issued.