Complaint·April 14, 2025

On 4/14/25 Licensing Program Analyst (LPA) M. Garza completed an unannounced complaint visit. LPA met with Executive Director, Robert Huntley, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety tour for resident in care. LPA observed residents in activities area, common areas and in rooms. Facility currently has 9 residents receiving hospice services. During visit LPA reviewed documentation and completed interviews. LPA completed review of their medical records and SIRs. During records review on 3/28/25, notes show there were 3 residents receiving treatment for rashes. Interviews conducted with staff indicate there are 3 residents that received treatment of some sort but staff was unable to say what for. Further review of MARS/CSMR did not indicate treatment was being received for scabies. Although the allegation may or may not have occurred, the allegation does not meet the preponderance of evidence standard per Title 22. The allegation is UNSUBSTANTIATED. Exit interview completed with Executive Director, Robert. A copy of this report provided.