Facility Evaluation Report

Licensing Program Analyst Manuel Monter conducted an unannounced case management- Incident visit, regarding a SOC341, personal rights violation, regarding resident R1. LPA also subsequently violations issued discovered during the complaint investigation for 26-AS-20250929092054. LPA with Administrator Camille Burke

Potential Violation discovered during compliant investigation process 26-AS-20250929092054

During complaint investigation, LPA randomly reviewed residents medications. LPA noted discrepancies with residents R15 and R16 medication records, when reviewing their Medication administration records, Centrally Stored Medication Records and a physical Pill count. At this time, this case in under review and Department will conduct a follow up visit , if warranted.

Follow up on incident dated February 9, 2026

On February 10, 2026, the Department received a SOC341 regarding resident R1. R1 has camera in his/her apartment. R1's Family member brought the footage to the facility on 2/09/2026. The video footage showed the following, On February 5, 2026 at around 2.00am, Staff S1 did rounds to check on residents. R1 came to R1's Apartment. S1 approached R1 and woke him/her up to change his/her brief. At first S1 stated to resident he/she wanted to check if his/her brief was wet but resident refused and told S1 to go away. S1 kept insisting to change resident's brief and was persistent in his/her approach to the point resident had increased agitation and became combative. (Continued on LIC809-C)