Facility Evaluation Report

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management visit in conjunction with Complaint #29-AS-20250514091509. The LPA arrived at 9:57AM and met with Executive Director (ED) Kellie Smith. Entrance interview conducted.

On 09/10/2025, the Complaint investigation was referred to Community Care Licensing Division’s (CCLD) Program Clinical Consultant (PCC) and assigned to Lorena Kho. PCC Kho reviewed documents including facility files, hospice records, and hospital records.

During today’s visit, LPA Huynh and the ED conducted a physical plant tour at 10:03AM and no immediate concerns were observed. The following was revealed during the Complaint investigation:

Between 05/05/2025 and 05/12/2025, Resident #1 (R1) sustained three (3) falls resulting in wrist fractures, a skin laceration, and significant physical pain. On the morning of 05/06/2025, R1 informed their Hospice nurse of an unwitnessed fall that occurred the evening of 05/05/2025. According to Hospice notes, facility staff denied the fall due to the absence of documentation. Later that same day, during a care plan meeting with R1’s family, the facility disclosed an unwitnessed fall that caused bruising and swelling to R1’s right shoulder, though no specific date or time was provided. The facility did not provide any additional information or documentation regarding the care plan meeting.