Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to follow up on an incident report submitted to the department on 05/02/2026. LPA was greeted and granted entry into the facility and explained the reason for the visit.

Incident report dated 04/28/2026 indicated Resident 1 (R1) was found by staff on the restroom floor. The resident reported pain and was transferred to Mission Hospital where the resident was diagnosed with a right hip fracture. Resident was transferred to a skilled nursing facility post-op and has not returned to the facility to date. Per physician report dated 08/20/2025, R1 is diagnosed with Dementia.

During the visit, LPA reviewed and obtained pertinent documentation such as facility notes.

Based on observations made during today's visit, NO deficiencies are being cited. Exit interview conducted and a copy of this report was provided.