Facility Evaluation Report

Licensing Program Analysts (LPA) B. Miranda conducted an unannounced visit today for the facility’s annual inspection. LPA introduced themselves and was allowed entrance into the facility. LPA met with Amber Land.

Facility is licensed for 6 residents and has a current census of 6. There are 2 residents on hospice and they are also receiving home health care through hospice. Plans are current, but facility was not able to provide staff training on Hospice Care Plans. Water temperature was checked in the kitchen which read at 113.5 degrees Fahrenheit. Fire Extinguisher was serviced November 18, 2025 and is within the safety regulation period. Smoke detectors were tested and in working order. Facility does not have carbon monoxide detectors. Facility has kitchen knives stored with cleaning supplies under the sink. Kitchen cabinet has a glue trap stored with clean dishes

Administrator Jennifer Thompson is no longer at the facility since February 2026. Currently there is not a qualified administrator in the facility. Staff Amber Land is working on obtaining RCFE Administrator's Certificate. Staff files were reviewed, are not complete. Staff training was conducted by Jennifer Thompson who was not certified as an RCFE Administrator, but as an ARF Administrator. Training verification was missing information regarding explanation of training conducted and hours completed for training. Resident files were reviewed and incomplete. Resident files are missing current and complete physician reports, appraisals/re-appraisals for change in condition. Facility could not provide a log for disaster drills that are conducted quarterly. Facility could not provide a disaster plan or infection control plan. Toxins and cleaning supplies are locked and inaccessible. There is a locked storage for medications. Hygiene products are accessible to resident’s in care; R1’s physician's report indicated R1 is at risk if hygiene products are accessible.