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25 | At 10:10 a.m. on 02/08/2024, 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. LPA and administrator toured the facility inside and out at 10:45 a.m.
A file review was conducted prior to today’s visit.
The facility was last visited on 02/14/2023 for a complaint visit. It is a single story building with seven (07) bedrooms, three (03) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 nonambulatory residents, of which six (06) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for four (04). Surveillance cameras are used in common and exterior areas.
The front access was gated with a doorbell for entry. LPA observed a maintained front yard and a ramp in good condition leading to the main entrance. Postings at the front included COVID precautions, administrator certificate, facility license, facility sketch, admission agreement, confidential complaints contacts, ombudsman contacts, emergency disaster plan, rights of resident councils, personal rights, theft and loss policy, resident list, and “No smoking – Oxygen in use” sign. A screening station was located at the main entrance. It contained a digital thermometer, visitor log, masks, and sanitizer.
Walls, floors, windows, screens, and blinds were clean and in good repair. At 11:00 a.m. LPA measured the room temperature to be 73.1 degrees Fahrenheit. Two (02) residents were observed in the living room watching television. Two (02) staff members were observed cleaning and preparing lunch. A whiteboard was hung in the living room denoting the date, staff present, and meal, snack, and activity times for the day. Board games, puzzles, and other activities were provided. A fireplace was appropriately grated and turned off. Medications were locked near the main entrance. Two (02) hallway closets contained extra linens and towels. A locked office in the rear of the facility contained personnel and resident files.
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