Routine inspection (multi-day)·March 14, 2025

Licensing Program Analyst (LPA) Teresa Camara conducted a continuation of the annual visit to review resident and staff records, emergency disaster plan, and other documentation. LPA met with administrator Sean Beharry and explained the reason for the visit. Resident Records: Resident records were checked for documents including but not limited to emergency identification form, consent forms, medical assessment, appraisal/needs and services plan, admission agreement and TB test results. These records appeared complete. Staff Records: Staff records were reviewed for documents including but not limited to fingerprint/background clearance, health screening, TB test results, and training. These records appeared complete. Medications: LPA reviewed medications for five residents. Medications appear to be given as prescribed based on the review of each centrally stored medication and destruction record and medications. Emergency Disaster Plan: LPA reviewed the facility's emergency disaster plan which appeared sufficient. The facility has an agreement with a facility out of the area to accept residents in the event the facility must be evacuated. Emergency evacuation drills are conducted quarterly with all staff. Infection Control Plan: LPA reviewed the facility's infection control plan which appeared sufficient. No deficiencies were observed. Exit interview conducted and report issued.