Facility Evaluation Report

Licensing Program Analyst (LPA) E. Conchas conducted an unannounced visit to the facility for an annual inspection. LPA met with administrator Iren Creighton.

LPA toured the facility inside and out with the administrator. The facility has no bodies of water. LPA was informed that the facility currently has one (1) resident in hospice. LPA was informed that the facility has a dementia care plan in place. The facility has a charged fire extinguisher, operating smoke alarms, and carbon monoxide detectors. Outdoor and indoor passageways were kept free of obstruction. The outside of the facility did not have a shaded area with seating. A technical was issued. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the residents. Cleaning supplies were stored in the laundry rooms. LPA observed that centrally stored medications were kept in a safe and locked place. Sharps were stored in the kitchen. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a menu available for review. LPA observed that the facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. LPA observed a activities calendar not updated. A technical was issued. LPA toured a the resident rooms. The resident bedrooms had the required furniture and functional lighting. LPA observed grab bars and nonskid mats in the bathrooms. LPA measured the hot water temperature throughout the facility and observed it was above 125 degrees F. A warning sign was posted. A technical was issued. The facility had a supply of additional linen and extra hygiene items for the residents. LPA also observed emergency supplies. The facility had a complete first aid kit and the last disaster drill was conducted on August 1, 2025.