A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Physical Plant & Environment Safety: The facility has 4 client bedrooms and 1 client bathroom currently occupying 4 clients. The Licensee lives in the facility and has 1 bedroom, and 1 bathroom dedicated for use. The staff have a staffroom and bathroom upstairs on 2nd floor and it is not currently being occupied by any staff. The facility is clean, safe and sanitary. The facility has smoke and carbon monoxide detectors were working at time of testing. The lighting and lamps are sufficient for the use of the facility and for the client’s comfort. The toilet, hand washing and bathing facilities are operational and secure grab bars are present. The pathways are clear of any obstructions. Disinfectants, cleaning solutions and poisons are inaccessible to clients in care locked in a closet off living room. The facility has sufficient space inside and outside for activities and visiting. The facility has a large yard and decks for client use with plenty of shade.

Operational Requirements: The facility has a current plan of operation and infection control plan on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 4 non-ambulatory, of which 2 may be bedridden.

Staffing, Personnel Records & Training: The facility employes 10 staff and, 1 Administrator. Staff records are kept confidential. LPA reviewed 5 staff files. Files reviewed had 1st Aid/CPR, Personnel Records/Application on file, Health screening with original TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions were on file. Administrator Certificate expires 7/30/2027. LPA reviewed staff training records, and various annual training were conducted for all staff. Continued 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.

Clients Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Reports, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. The Facility does handle cash resources for 2 clients in care. LPA audited 2 clients’ funds with ledgers, cash, and receipts. Facility does submit incident reports to the department when required.

Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables to meet the food service requirements. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the clients want them. An emergency supply of food and water is available. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean. Water was tested at 106.2 degrees.

Health Related Services: Facility provides Centrally Stored Medications to all clients in care. Clients’ medication records for prescriptions had doctors’ orders present. The facility uses the Medication Administration Records (MAR) and Centrally Stored Medication and Destruct Record (CSMDR) for client medications. LPA audited 4 residents’ medication, no current client medications were expired, prescription labels were not altered, and medications were stored in original containers. During review of kitchen area, LPA found an unlocked cabinet with medications, most of the medications were over the counter medications, but one bottle was a liquid pain medication for a client that passed away over 2 years ago. Citation regarding the concerns of unlocked accessible medication was cited see 809-D.

Incidental Medical Services: Facility provides transportation to medical and dental appointments when needed.

Disaster Preparedness: The current emergency disaster forms were posted. The fire extinguisher was charged and a receipt showing purchase date in February of 2026. 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.

Exit interview conducted, appeal rights printed and copy of report printed for to Administrator.