Facility Evaluation Report

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 at 12:15pm. During today’s visit, LPA met with Erlinda Pinkston, Administrator Designee (AD) .

The facility is a four bedroom, three bathroom, single story residence with an approved fire clearance of six non-ambulatory residents of which one may be bedridden . The facility currently has a census of six residents in care and is approved with a hospice waiver for six.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in three of three resident bathrooms, and testing auditory devices on all exits . The hot water temperature measured between 116.0 and 119.8 degrees Fahrenheit and all smoke detectors were operational . The fire extinguisher is charged and was serviced on February 22, 2024. The facility has not conducted a fire drill in this quarter and a deficiency will be given.

LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. Sharps and disinfectants were secured. LPA observed medication storage and reviewed the centrally stored medications. Per review it is not clear if medications are being given as prescribed and a deficiency will be given.

LPA observed residents finishing lunch. Five of the residents watched a movie in the living room and one