Most inspections found no deficiencies until the annual inspection on March 26, 2025, which identified several issues including non-operational stove burners and exit alarms, an unsecured utility knife, incomplete medication records, and insufficient emergency water supply. These findings included immediate health and safety risks related to fire safety and sharp object accessibility. A follow-up inspection on September 23, 2025, showed partial improvement with the stove replaced, but two exit alarms remained non-operational, so the deficiency was not fully corrected by the due date. Earlier reports, such as the one from September 20, 2021, were clean with no deficiencies noted. There is some improvement over time, but key safety issues remain unresolved as of the most recent inspection.
Deficiencies per Year
43210
2021
2025
HighModerate
Census Over Time
CensusCapacity
Inspection Report Plan of CorrectionCensus: 4Capacity: 6Deficiencies: 1Sep 23, 2025
Visit Reason
An unannounced Plan of Corrections Inspection was conducted to verify correction of a deficiency issued on 2025-03-26 during the required annual inspection.
Findings
The stove top has been replaced and is operational; however, two out of four auditory exit alarms are not operational. The Plan of Corrections has not been fulfilled by the assigned due date, thus the deficiency remains.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Two out of four auditory exit alarms are not operational which poses a potential health and safety risk to persons in care.
An unannounced required annual visit was conducted to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to have several deficiencies including non-operational stove burners and audible exit alarms, unsecured utility knife, lack of PRN medication record keeping, and insufficient emergency water supply. Other areas such as resident rooms, bathrooms, food storage, and emergency plans were found to be in compliance.
Severity Breakdown
Type A: 2Type B: 2
Deficiencies (4)
Description
Severity
6 out of 6 stove burners are not operational without an external ignitor and 4 out of 4 exits have non-operational audible exit alarms posing an immediate health and safety risk.
Type A
A utility knife was found in an unlocked drawer in the living room next to the kitchen posing an immediate health and safety risk.
Type A
PRN medications are not recorded when administered, posing a potential health, safety or personal rights risk.
Type B
Facility has only 2 gallons of emergency water available for 4 residents and 2 staff members, posing a potential health, safety or personal rights risk.
Type B
Report Facts
Census: 4Total Capacity: 6Deficiencies cited: 4Emergency water supply: 2Emergency water supply plan: 15
Licensing Program Analyst Michelle Reed made an unannounced visit to conduct an Annual visit focusing on Infection Control at the facility.
Findings
No deficiencies were noted during the visit. The facility was found to have adequate infection control measures including posted Covid signs, sanitization stations, sufficient PPE supplies, social distancing, and emergency plans.
Report Facts
PPE supply duration: 30Facility capacity: 6Resident census: 5
Employees Mentioned
Name
Title
Context
Michelle Reed
Licensing Program Analyst
Conducted the inspection visit.
Larry Lindsey
Administrator
Facility administrator present during the visit and named in the report.
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