Facility Evaluation Report

Licensing Program Analysts (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 9:45 a.m., the LPA met with staff and explained the reason for the visit. At 10:01 a.m., the Co-Administrator, Johnna Udden arrived at the facility. At 10:15 a.m., Administrator, Helen Rose T. Busch arrived at the facility.

RECORD REVIEW: Between 10:02 a.m. and 11:30 a.m., the LPA conducted a file review for all five (5) residents and staff regularly scheduled and observed the following: Staff have current first aid and training documentation showing required training completed. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All files were in order. The LPA observed documentation for the Infection Control Plan and Emergency and Disaster Plan. The last emergency disaster drill took place on 11/30/2025.

At 12:34 p.m., the LPA conducted a review of medication and medication documentation with Co-Administrator, Johnna Udden for three (3) residents. Medications are located in locked cabinets adjacent to the kitchen and living room.

At 1:01 p.m., the LPA, along with Co-Administrator, Johnna Udden toured the physical plant areas inside and outside to ensure there are no health and safety hazards. KITCHEN: The LPA observed the kitchen and dining area. Knives are stored in a locked drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:01 p.m., hot water measured at 110.1-degree Fahrenheit. Continued on LIC-809-C.