Facility Evaluation Report

Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a case management visit on incident reports received. LPA met with RACHELLE REYES and explained the purpose of the visit.

The incident reports received were dated for the month of October 2025, regarding resident falls, deaths and the facility dietitian and a power outage. LPA asked for documents including care plans, discharge paperwork from the hospital if available, physician report for each resident R1-R9 also a staff schedule for the month of October 2025. LPA Lewis also requested the death certificate for R5. As of today’s visit, the incident reports for R1-R4,R6-R7 are closed with no further follow-up needed. LPA also received a contract for the nutrition consultant and was informed the facility was waiting for a time schedule for the consultant. LPA also requested power outage procedures. Needs and service plans will be emailed to LPA Lewis by EOD 10/31/2025 due to system outage.

Part of this matter is still under investigation; LPA will return at a later date to deliver the findings.

Exit interview and copy of the report given.