Facility Evaluation Report

On December 1, 2025 Licensing Program Analyst (LPA) Garlli Tat conducted an unannounced case management visit. LPA was greeted and granted entry by staff and explained the reason for the visit.

After entering the facility, LPA was led on a tour of the facility with staff. Staff called Lead Caregiver, who arrived shortly thereafter. There were six residents present at the time of the case management visit including Resident 1 (R1). All residents were observed in the living room at the time of the visit. R1 was asleep, but later woke up. LPA attempted to interview R1, but R1 did not respond. R1 is diagnosed with Dementia.

Staff was asked about R1 during the visit. Staff reported that R1 is usually independent. Staff reported R1 is a fall risk due to her Dementia. R1 last had a fall on October 15, 2025. LPA was informed that bed rails were recommended for R1, but daughter rejected the idea at the time thinking that it would be more risky for R1 because they might climb over it and fall. R1 uses a triangular pillow for knees for support and is carried by two staff for transfer.

R1’s daughter has been in contact with the facility. R1's daughter was informed about hospitalization and surgery.

Staff provided relevant documents for R1 and night shift staff at the time of the fall.

No deficiencies are being cited as a result of today’s case management visit. No health and safety concerns were noted during the visit. LPA consulted with Lead Caregiver regarding reporting requirements.

An exit interview was conducted, and a copy of this report was provided.