Facility Evaluation Report

Licensing Program Analyst (LPA) Elizabeth Irra conducted a case management visit pertaining to the Administrator not submitting Special Incident Reports (SIRs) for C-1 after C-1 sustained an ankle fracture in which it later became a Stage 4 wound (investigated via complaint control number: 28-AS-20250317150927). LPA met with Rosario Nicolas and discussed the purpose of today’s visit.

During the course of the investigation, Administrator admitted to submitting the initial SIR for C-1 for the ankle fracture which occurred on 11/19/24 and did not submit SIRs for C-1's change in condition.

Exit interview conducted and a copy of this report was provided to Rosario Nicolas.