Facility Evaluation Report

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 3/18/26 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with Administrator who assisted with the visit.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home is very clean and residents stated they are happy with care.

LPA reviewed 2 resident files. Files are complete. PRN administration records need to be in place. R1 and R2 needs and services are to be updated and reviewed with residents or representatives.

LPA reviewed 2 staff file. Facility records and staff interview found that staff present has not participated in quarterly emergency drills and that staff training requirements are not met for the past 12 months. Training resource information is provided.

LPA discussed with staff the possible need for a signal system for R1 to call for assistance.

Licensee will submit a copy of current liability insurance certificate.

Deficiencies are being cited as a result of todays inspection.

Exit interview conducted with licensee and copy of report left at the facility.