Post-licensing visit·July 16, 2025

Licensing Program Analysts (LPA) Sarah Hurt and Shawna Doucette arrived for a post licensing inspection. LPA was met by Administrator Linda Pothyress. The facility currently has a census of 72 residents at the time of this inspection. A complete tour of the facility was done. Medications are properly stored and secured in a locked cabinet. Food supply was checked and a 2 day supply of perishable and 7 day supply of non-perishable was checked. Fire extinguisher/smoke detectors and buildings and grounds are checked and observed to be operational. LPA's reviewed facility Plan of Operation, Infection Control Plan, and Emergency Disaster Plan. A sample of resident's and staff's files were checked. Resident's files have signed Admission Agreements and Physicians reports. Staff are fingerprinted clear and associated and have current CPR. LPA's observed Resident 1 in room 111 has a folding lawn type chair in bedroom as furniture. LPA's observed Resident 2 has medications out and accessible despite Physicians report documenting they are not able to administer own medications. LPA's observed Resident 3 in room 147 sink faucet water temperature measured to be 130 degrees. Resident 4 does not have required hospice care plan. The following deficiencies are being cited for this visit. Exit interview conducted with Licensee Administrator Linda Pothyress, and a copy of this report provided.