Facility Evaluation Report

On 4/9/26, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Executive Director (ED), Michael Clymo. Resident Care Director and Memory Care Director (interim) also joined the discussion.

The department received incident reports of residents (R1, R2, R3 and R4) falls that resulted in injuries. Each fall was discussed to review causes (if known) and staff care at the time.

LPA found no staff action or inaction as contributing to the falls reviewed.

LPA and Sonrisa staff discussed, in detail, staff observations of falls for possible causes, staff training (the department's TSP webinar and web page as a resource), collaboration with residents, family and medical providers to ensure all reasonable measures are in place to reduce the likelihood of future falls.

As a result of today’s inspection, no deficiencies were noted.

Report reviewed. Copy of report to be provided by email