Facility Evaluation Report

On 1/22/26, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Admin

During complaint investigations for complaints 59-AS-20251119202205 and 59-AS-20251208154031 LPA Mknelly obtained evidence for the following additional violations:

87465 Incidental Medical and Dental Care (h)(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. There was not a recording of R1 skin treatment in the centrally stored medication record.

87355 Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility. This requirement was not met based on records review and interview that found S1 and S2 did not have verified clearance prior to living and working at the home 5/27/25- 5/28-25.

87405 Administrator - Qualifications and Duties (d) (2) Knowledge of and ability to

conform to the applicable laws, rules and regulations. Administrator failed to hiring, train, seek criminal record clearance of S1 and S2, meet reporting requirements, ensure fire safety, create initiate resident behavior plans, ensure infection control and to have been arguing with family in the presence of residents.