Facility Evaluation Report

Today Licensing Program Manager Liza King and Licensing Program Analyst (LPA) Kesha Lewis made an unannounced visit to this facility to follow up on incident reports received from the facility and documentation requested by the Department. LPA and LPM met with the Administrator Carolyn Appeal. The purpose of the visit was explained.

Current census is 67 in hospital 5 on hospice 5

The Regional Office (RO) received an LIC624 on 03/17/26 re an incident that occurred on 3/16/26 for R1 and R2 in which an altercation between the two had occurred. The following documents were reviewed. Admissions Agreement, Emergency Contact Sheet, LIC602, Preplacement appraisal and any reappraisal, Needs and Services Plans, MAR for Jan 2026 to current , Any incident reports Jan 2026 to current , Any Service Notes for Jan 2026 to current, Any discharge summaries for Jan 2026 to current , Resident Roster, Staff Roster with telephone numbers. The incident resulted in R1 being injured. A review of the records revealed there was no update to the care plan. R1 had not been administered any pain medication, since return from the hospital more than a week ago. When LPM asked R1 how they were doing they expressed pain and were able to identify where.

Additionally the RO conducted a follow up visit re LIC 624 received for R3, R4, R5, R6, R8 in which falls occurred and residients were hospitalized. Similar documentation was requested from the licensee to be submitted to the RO by 03/26/26, proof of email was observed and documents were printed and provided during visit. The RO will review the documentation, conduct interviews and return at a later date to address any concerns.