Complaint·March 16, 2026

On 03/16/26 Licensing program Analyst (LPA) M. Garza arrived at the facility for an unannounced complaint visit. LPA met with Executive Director, Sheree Addison, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. LPA observed residents in rooms in common areas and in kitchenetts getting ready for lunch. During viists interviews were conducted and documentation was requested and reviewed. Review of records indicated that R1 was bedridden and receiving hospice services. Care plan indicated that R1 was a high risk for pressure injuries and noted pressure injuries being treated at time of initiation of services. Interviews indicated that R1 was being turned per hospice directions. Hospice notes further stated that the pressure injuries for R1 were not increasing/becoming worse. During visits LPA completed random room checks each visit. Visits conducted on 8/6/25, 8/26/25, 11/24/25, 2/24/26 and 3/16/26. During each visit LPA did not observe an odor of urine in the facility/rooms checked. Interviews did not disclose an issue with residents being changed in a timely manner. Although the allegations may or may not have occurred the preponderance of evidence standard has not been met. The allegations listed above are UNSUBSTANTIATED. No deficiencies cited during todays visit. Exit interview completed with Executive Director, Sheree. A copy of this report provided.