Facility Evaluation Report

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 (S1) at 8:15am. LPA met with Administrator, Carmen Achim and explained the purpose of the visit.

LPA was informed that the facility is currently going through a Change of Ownership (CHOW). The facility is a seven bedroom, single story residence with an approved fire clearance of six non-ambulatory residents and an approved hospice waiver for three.. The facility currently has a census of six residents 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 six of six resident bathrooms, and testing auditory devices on all exits, The hot water temperature measured between 113.7 and 116.6 degrees Fahrenheit and all smoke detectors were operational . The fire extinguisher is charged and was serviced on March 7, 2025. The facility’s last fire drill was conducted on September 30, 2025. 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 . More than fifteen gallons of water was observed in the garage with the emergency food supply. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. A PRN/ As Needed log is available but has not been used due to residents not requiring as needed medications A First Aid Kit was observed with all of the required elements.

LPA toured the exterior of the property and observed a shaded seating area and all exterior exit gates were self-latching. There are no hazards or obstructions in outdoor pathways and there is plenty of space for activities. LPA also observed the PUB 475 and Long Term Care Ombudsman posters posted.