Physical Plant & Environment Safety: LPA toured rooms and observed that rooms were tidy, the lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secure grab bars are present. The showers have non-skid flooring. The pathways are clear of any obstructions. Facility is well lit inside for safety. Disinfectants and cleaning solutions are inaccessible to residents in care and locked in kitchen closet and housekeeping room. The facility has sufficient space inside and outside for activities and visiting. The fire extinguishers viewed were in the green charged and scheduled for inspection. The facility has carbon monoxide detectors throughout the facility, and a sprinkler system. Sprinkler system was certified tested on 5/14/26.

Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 140. The fire clearance is granted for 140 non-ambulatory of which 10 may be bedridden. Hospice waiver approved for 20 residents. The facility currently has 83 residents. There are currently 6 residents on hospice. Certificate of liability expires 10/1/27.

(Continued on 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.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidential. Facility does submit incident reports to the department when required. LPA reviewed 10 resident files, all required documentation was present, and all forms were legible.

Activities: During visit, LPA witnessed activities, toured garden where residents were walking, visiting on the patio, and enjoying pets in the community. Garden area is large, with multiple paths, shaded areas, and plants. It was clean, plants are well landscaped and garden is gated. Items discussed with facility regarding potential hazards, all items were addressed during LPA’s visit and updates are scheduled. Copies of the last 10 months’ activity calendars were provided to LPA.

Food Service: The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored, and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies.

Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed a sampling of residents’ medications, no labels were altered, medications were documented, counts were correct, and all medications were kept in their original containers. Discussion of medication destruction process and evaluating residents who do not have medication management was conducted.

Disaster Preparedness: The current emergency disaster forms were reviewed and a copy collected. Suggestions made regarding power outages and drills. The facility conducts monthly disaster drill/training, last one was conducted on 10/9/26. Emergency exits and telephone numbers were are available. A set of keys is available for staff on all shifts to access full facility in an emergency.

Exit interview conducted, no deficiencies issues and copy of report printed for Administrator.