COMMON AREAS: This includes the living room, open office and dining room. At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 1:43 p.m., hardwire combination of smoke / carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 06/10/2026 The emergency exiting plans/sketch are posted in every room. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. Activities were observed in the common areas. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises. Auditory alarms at the entrances and exits were observed and functional at the time of the visit. LPA observed surveillance cameras installed in the common areas of the facility. The Administrator presented the live monitoring screen to the LPA, confirming that all cameras were functioning properly and that none of them were equipped with audio capability.

INTERVIEWS: Starting at approx. 12:47 p.m. and throughout the visit two (2) staff and two (2) resident interviews were conducted. Staff interviews revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit. Report Continued on LIC 809-C PAGE 2...

• 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.

BEDROOMS: There are nine (9) total bedrooms in the facility; six (6) bedrooms are designated as private, single occupancy, resident rooms and three (3) staff rooms. The staff rooms are kept locked at all times and observed to be occupied by staff. Six (6) of six (6) resident rooms have exits to the exterior. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are five (5) total restrooms. Two (2) are designated as a shared / common resident restroom, One (1) is designated as a private resident restroom, and two (2) are designated as staff and guest restrooms. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all resident restrooms and ranged between 105.8- 118.1 degrees Fahrenheit, all within the required range. LPA observed storage space closets in hallway containing extra clean linens and towels for resident use.

LAUNDRY AREA: LPA observed an open laundry area adjacent to the kitchen, and locked supply closet. Laundry area has a washer and dryer. Laundry supplies are kept locked in the supply closet adjacent to the washer and dryer.

GARAGE: LPA observed the locked facility garage, which has been converted with permits to a living unit for staff. The garage contains two (2) staff rooms, a staff restroom, staff kitchen area, as well as storage for incontinence are items and emergency food and water supply.

KITCHEN: The LPA inspected the kitchen/food service area. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 116.6 degrees Fahrenheit. Cleaning supplies and other chemicals are kept in the chemical closet adjacent to the washer and dryer unit locked and inaccessible to residents in care. Report Continued on LIC 809-C PAGE 3...

RECORDS: Records were reviewed beginning at 1:11 p.m. Resident Records Five (5) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Pre- admission appraisal, LIC627(c) Consent for Treatment form, Home Health records, Hospice records, PRN authorization letters, and current needs and services plan. All records were in order. Personnel Records Five (5) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. At the time of the visit LPA conducted a business search to ensure the Business / LLC is in good standing ; LLC is Active and in good standing.

INFECTION CONTROL/ EMERGENCY DISASTER PLANNING: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required on 01/29/26 and 05/27/26. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard. The last emergency disaster drill took place on 09/10/26 and are conducted quarterly.

MEDICATIONS: Medication review began at approximately 2:30 p.m. Medications are centrally stored and locked in a cabinet in the kitchen adjacent to the living room. Medications for three (3) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed during review.

DOCUMENTS: Documents obtained during the visit include LIC 500 -facility roster, LIC 9020A- Resident roster, copy of the Limited Liability insurance, and LIC 610E -Emergency disaster plan.

At the time if the visit the LPA reviewed the facilities contact information on file including phone numbers, email and annual fees. Administrator confirmed that all information is accurate.

No citations issued at this time. Exit interview conducted. Copy of report reviewed and provided.