Facility Evaluation Report

On 1/29/30, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management and met with Regional Clinical Specialist (RCS) who requested a meeting with LPA to assist in resolving outstanding plans of correction. A licensee representative had asked for assistance.

LPA and RCS discussed incidents and visits that resulted in citations issued 1/14/25 and 1/22/25 for which plans of corrections have not submitted to date. LPA reestablished time-limes and content needed for outstanding POCs.

Licensee, or designee, will email to LPA 1/30/25 to present the plans of corrections for these outstanding A citations be submitted by 2/3/24. Additionally B citation POCs are still due on time.

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

Report reviewed with . Copy of report and appeal rights provided