Facility Evaluation Report

On December 12, 2025, Licensing Program Analysts (LPAs) Eboni Bentley and Jenifer Tirre conducted an unannounced required 1-Year Annual Continuation visit using the CARE Inspection Tool. Upon arrival at the facility, LPAs introduced self and were granted entry into the facility by staff, after stating the purpose of the visit. Executive Director/Administrator (ED) Sarah DeVore arrived at the facility and remained to assist during the visit.

The facility is a five-level structure licensed to operate for 164 non-ambulatory residents with a hospice waiver for 25. All required postings were observed in the entry way of the facility. The Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the correct size. Emergency disaster drills were last conducted on November 18 and November 28, 2025. First aid kit contains all the necessary elements. Smoke alarms and carbon monoxide detectors were lasted inspected by Johnson Controls on October 3 and October 8, 2025, per the inspection report. Nineteen fire extinguishers were observed throughout the facility. All were mounted, charged, and last serviced on June 1, 2025. Liability Insurance is effective February 1, 2025 through February 1, 2026.

Cleaning supplies and sharp items were observed inaccessible to residents in care. LPA conducted an audit of ten resident files, six staff files, and medication and medication administration review. Staff interviews were conducted.

No deficiencies are being cited during today's visit. An exit interview was conducted, and a copy of this report was provided to Executive Director/Administrator Sarah DeVore at exit.