Facility Evaluation Report

On July 02, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a unannounced Case Management – Health Check inspection visit. LPA met with the Administrator (ADM) Zach Pilkerton and disclosed the purpose of the inspection. There were 33 residents in care and 11 staff members present at the time of the inspection.

LPA initiated a walk-through of the facility, accompanied by the Administrator.

LPA inspected random resident rooms. LPA inspected attached bathrooms in these random rooms. The hot water temperature at the sink faucets measured between 112.3°F and 112.6°F. LPA inspected common areas and observed eight (8) residents sitting in the front room, seven (7) residents watching TV in the TV room, and one (1) resident in the dining room. LPA inspected the kitchen next to the front lobby area. The refrigerator and freezer were checked, and there was a sufficient supply of fresh perishable food for two (2) days and nonperishable staples for seven (7) days. LPA inspected the pantry storage and laundry area in the basement, one level below the main floor.

LPA toured the outside areas and found passageways free of obstructions, and without any blocking or tripping hazards. No accessible bodies of water were observed.

LPA observed locked centrally stored medication cart in the medication room. Medications were organized separately for each resident. At 09:10 AM, Centrally Stored Medication Records were reviewed, and a medication count check was performed. LPA observed that the medication count for one (1) bedtime + dinner narcotic medication for one resident (R1) was found to be inaccurate and one less day of medication was administered to R1 for this medicine.