Routine inspection·February 7, 2025

Licensing Program Analysts (LPAs) Angelica Boyles and Arian Golbakhsh made an unannounced visit to conduct the required annual Inspection. LPAs were granted entry into the facility by Administrator Susan O'Shaughnessy, after identifying themselves and stating the purpose of the inspection. The facility serves 110 elderly residents, age 60 and above, all whom may be non-ambulatory. Approved for ten (10) bedridden residents. The facility is approved for locked perimeter. LPAs were accompanied by Administrator Susan O'Shaughnessy for a tour of the facility which included the outside areas and a sample of resident units, the dining area, and recreation rooms. Exterior and interior passageways were free from obstructions. Pull cords are present and easily assessable to residents. Resident and facility room temperatures were within a comfortable and compliant range. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. Facility has a two day supply of perishable and a seven day supply of nonperishable food items. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closet. The medication carts were locked and medications were labeled and kept in compliance with label instructions. [Continued on 809-C] [Continued from 809] LPAs interviewed staff and clients. LPAs reviewed multiple staff and client files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPAs also conducted a review of In-service training procedures. There are large designated activity rooms and gathering areas throughout facility. At the time of visit, LPAs observed two different group activities in which many residents were participating. LPAs observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No deficiencies were sited at the time of visit. A final exit interview and a copy of this report was provided to Administrator Susan O’Shaughnessy whose signature on this form acknowledges receipt of these documents.