Routine inspection (multi-day)·March 26, 2025

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a continuation of the required annual visit at 02:17 PM. LPA met with facility staff who contacted the Assistant Manager and the Administrator Grace Hartnett. Entrance interview conducted and the reason for the visit was explained. INTERVIEWS: LPA interviewed five (5) staff members. All staff members interviewed were knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. RECORD REVIEW: Record review began at 02:40 PM. Resident records were reviewed for documents including, but not limited to: TB test, physician's report, needs and service appraisal, consent forms, admission agreements, and personal rights. Ten (10) resident files were reviewed. All resident files contained all required documentation and signatures. No deficiencies were observed during record review. During today’s visit LPA obtained a copy of the facility’s updated LIC 500. Due to time constraints LPA will return at a later date to conduct staff file review and to review the facility’s emergency disaster plan and infection control plan. No deficiencies were observed during today’s inspection. Exit interview conducted and copy of the report was issued.