Facility Evaluation Report

Licensing Program Analysts (LPAs) Cassie Yang and Kevin Mknelly arrived at the facility to conduct a case management visit regarding an incident that LPAs were made aware of during LPAs' visit. LPA met with Administrator and explained the purpose of the visit.

Upon LPAs' arrival, LPAs were informed that today's census was five (5) residents in care as resident (R1) had recently passed away in the month of December 2025. File review was conducted and observed that R1 was not on hospice services. Administrator stated death report was submitted but to the wrong regional office. LPA was provided a copy of R1's death report. File review revealed R1 passed away December 18, 2025 but death report was not submitted to Licensing until December 29, 2025.

LPAs and Administrator discussed the importance of submitting death reports in a timely manner within the seven days of occurrence. At this time, this matter remains under review by the Department.

Deficiencies cited. As this is a repeated violation, an additional $250 civil penalty has been assessed.

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