Complaint·May 19, 2025

On 5/19/2025 Licensing Program Analyst (LPA) M. Garza completed an unannounced complaint visit. LPA was informed Executive Director (ED), Robert Huntley and Licensed Vocational Nurse (LVN), Gabriel Facio were out of the facility and unavailable currently. LPA met with Business Office Manager, Bryant Ward, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. Residents were observed in rooms and common areas. ED and LVN arrived some time later. During investigation LPA completed interviews with staff, resident family members and residents. LPA collected and reviewed documentation (Resident roster and room numbers, staff schedule, special incident reports for R1, pre-placement appraisals, admission orders, physicians reports, hospice care plans, and review of physicians prescriptions). During visit it was disclosed R1 is utilizing a soft tie while in the wheelchair. Review of physicians orders do not show a prescription for a soft tie to be used. The preponderance of evidence standard has been met and the allegation above is SUBSTANTIATED. Deficiencies cited per Title 22. Exit interview conducted with Executive Director, Robert and LVN, Gabriel. A copy of this report deficiencies and appeal rights provided.