Facility Evaluation Report

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct an annual inspection. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Director of Health Services Breanna Creekmore and Administrator Sheila Fike arrived shortly after.

The facility is a single story building with an approved fire clearance of forty-two non-ambulatory residents of which eighteen may be on hospice. The facility currently has a census of thirty-four residents in care.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing hot water temperature in five bathrooms, and testing auditory delayed egress devices. The hot water temperature measured between 106.8 and 118.7 degrees Fahrenheit. LPA Mendivil observed the facility to have two day perishables and seven day non-perishables, facility stores emergency food and water in dry storage. LPA observed medications in a locked med-cart located inside of locked wellness room. LPA Mendivil reviewed Electronic Medication Administration Record for three residents, and medications were given as prescribed. LPA observed two separate activity calendars posted in entryway and hallway leading to the dining room. LPA observed residents participating in activities and in their bedrooms. LPA observed six residents rooms and all had required items including bed, chair, dresser/closet and ample lighting. LPA Mendivil reviewed six resident files and five staff files. LPA observed Staff 1 - 5 did not have the required training. The facility conducted a fire drill on 01/28/2026 conducted with Fire Safety Services, INC.

Based on the observations made the following is being cited. An exit interview was conducted and a copy of this report was provided.