Facility Evaluation Report

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a continuation of the required annual visit at 10:28 AM. LPA met with facility Administrator Grace Hartnett. Entrance interview conducted and the reason for the visit was explained.

RECORD REVIEW: Record review began at 10:40 AM. Staff records were reviewed for documents including, but not limited to: TB test, physician's report, criminal record clearance, and first aid training. five (5) staff files were reviewed. All staff files contained all required documentation and trainings. No deficiencies were observed during record review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the

facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. The facility’s emergency disaster plan is up to date and is adequate. Disaster drills are conducted quarterly and the facility's last emergency disaster drill was conducted on 03/17/2025. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator.

During today’s visit LPA obtained a copy of the facility’s liability insurance.

No deficiencies were observed during today’s inspection. Exit interview conducted and copy of the report was issued.