Facility Evaluation Report

On November 20, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident report that was received on November 18, 2025. LPA met with Administrator and explained the purpose of the visit.

The incident report reviewed indicated on November 17, 2025, Facility was notified by resident (R1)'s doctor that R1 will need to be seen immediately for evaluation. R1 declined medical attention with Alpha One, and refused to be seen by medical provider. Refusal was notified to R1's responsible party and R1's primary care physician.

Today's visit, LPA was informed that R1 was admitted to the facility with a stage 2 wound ulcer. R1 has home health coming to the facility approximately twice a week for cleaning and dressing. Home health has reported to Administrator that there is no concerns; however, it was observed by the facility the condition has worsen with discharge and smell. New staging has not be conducted as R1 has refused to be re-evaluated. Administrator has a meeting pending with R1's responsible party in regards to a higher level of care which may result to a 30 day eviction if R1's wounds continue to worsen.

At this time, Administrator will continue monitoring and communicate with R1's primary care physician and R1's responsible party. Administrator was advised to comply with PIN 22-24-ASC. Additionally, Administrator was advised to submit a draft of the eviction to Licensing to review to ensure it is lawful.

This matter will remain ongoing until resolved. No deficiencies cited.

Exit interview and a copy of the report and appeal rights provided.