Facility Evaluation Report

On 01/05/2026 at 1:30PM, Licensing Program Analysts (LPAs) Andrew Christy and Kelly Nguyen conducted a Case Management regarding documentation during a complaint investigation. LPAs explained the nature of the case management to Kathleen McCarron, executive director.

During the complaint investigation, LPAs conducted file review for a resident (R1) to ensure reporting requirements were being met. In the file, LPAs did not see incident reports for a fall in November and a wound being treated in December, though executive director claims they were submitted. LPAs requested these documents be sent to them by 01/07/2026, as well as the fax confirmation that they normally include with all sent incident reports.

In addition, LPAs request the care notes done for the patient to be sent on 01/16/2025, covering the dates of 01/05/2026-01/15/2026.

No deficiencies cited during visit. Exit interview conducted and a copy of this report was made available to the executive director.