Facility Evaluation Report

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 09:49 AM to conduct an unannounced Case Management - Deficiencies visit at the facility today. LPA met with facility Executive Director (ED) Grace Hartnett entrance interview conducted and the reason for the visit was explained.

The purpose of today’s visit was to follow-up on two (2) self-reported incidents that occurred on 10/04/2025 and 10/12/2025. During today’s visit, the LPA conducted interviews with the Executive Director (ED) and the Director of Assisted Living (DOAL), conducted a file review for one (1) resident, and conducted a medication review for one (1) resident between approximately 09:52 AM and 01:50 PM.

On 11/04/2025 at 6:37 PM and on 11/0 5/2025 at 1:32 PM Community Care Licensing Division (CCLD) received two (2) self-reported incident reports pertaining to Resident #1 (R1). The two incidents occurred at the facility on 10/04/2025 at 11:00 AM and on 10/12/2025 at 10:00 AM. LPA interviewed the ED and DOAL and asked why the reports were not submitted to CCLD in a timely manner. ED and DOAL explained that a combination of confusion between R1's hospice company not receiving a medication order and the DOAL being out sick from the facility during the times the incidents occurred both contributed to the incident reports being submitted outside of the required time frame. LPA informed ED and DOAL th at a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence any incident which threatens the welfare, safety or health of any resident . ED and DOAL confirmed that they are aware of the reporting requirement and agreed to submit all future reports to CCLD in a timely manner and ensure someone in leadership is available to review/approve reports for submission to CCLD in the event of an absence of the ED or DOAL.