complaint·July 24, 2025

One resident confirmed to need assistance for all activities of daily living, but review of physician reports show identifies resident as non-ambulatory. In addition, a record review of physicians reports for hospice residents revealed that nine (9) out of nine (9) hospice residents’ physicians reports identified residents as non-ambulatory. During facility tour, LPA observed resident R10 to be in bed with half bed rails which physician report identified resident as non-ambulatory. Seven (7) out of seven (7) staff interviews revealed that the facility has no bedridden residents. Some residents were identified as needing repositioning, but record reviews identified residents as being bedbound. Services provided were for transferring, feeding, dressing or showers. Based upon the investigation, client and staff interviews, document review, and LPA observations, the facility is not in violation with their fire clearance. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . Exit interview was held with Assistant Administrator Denise Sutton. A copy of the report was provided.