Facility Evaluation Report

On 8/7/2026 Licensing Program Manager (LPM) Christine Kabariti and Licensing Program Analyst (LPA) Coryse Ngangmenyi conducted an unannounced Case Management - Incident visit.

LPM and LPA met with administrator (ADM) Judy Reyes.

On 07/31/2026, the Department received an incident report for resident (R1) regarding a pressure injury that developed from a stage 3 to a stage 4 on 7/30/26.

On 7/31/26, LPA Partoza spoke with a staff who stated that R1 was seen by a wound care doctor "a couple of month ago". Staff stated the facility kept delaying to bring R1 to the doctor because there is no staff to take R1. Staff stated the wound visit should be once a month, but R1 was not seen for 2 months. Staff stated the last time R1 was seen was in 06/25/2026.

During today's visit, ADM was interviewed and based on interview R1 was seen by a Wound Care Doctor in March, April, June and July 2026.

ADM states R1 was not seen in May 2026 due to being short staff. ADM stated facility tried to reschedule the appointment but the doctor was not available. The soonest availability was 06/01/2026. ADM states the appointment was rescheduled from 06/01/2026 to 06/25/2026 because there was no staff available on 06/01/2026.