Facility Evaluation Report

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA met with Lorna Smith, Administrator.

The facility is a four bedroom, single- story home with an approved fire clearance of six non-ambulatory residents with a hospice waiver for six. The facility currently has a census of one resident in care.

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 one of one resident bathrooms, and testing auditory devices on all exits . The hot water temperature measured 105.6 degrees Fahrenheit. The fire extinguishers are charged and were serviced on October 20, 2022. The facility’s last fire drill was conducted on March 22, 2025 . The facility fire alarms and carbon monoxide detectors were not operational and a deficiency was 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 for one resident. All appliances in the facility are operational. Knives and sharps were secured in a locked cabinet. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. LPA observed the First Aid Kit had all the required elements.

Three of four vacant resident rooms did not have the required beds or linens. Chairs, drawers and lamps were observed in all bedrooms and window screens were maintained and rooms were clean.