Complaint·May 21, 2026

It was alleged that facility did not ensure resident was repositioned causing bruising. Per interviews with 5 out of 5 staff stated that R1 was repositioned. Per review of care notes bruising was noticed on R1’s heel which was notated by hospice. Interviews with staff stated they would not notate in care plans when a resident was repositioned. Staff stated they only chart issues out of the norm for the resident. It was alleged that facility is charging for services not provided. Interviews with 5 out of 5 staff stated they were providing all services for R1. Interviews with 6 out of 6 residents stated all needs are being met and all services are being provided. It was alleged that Facility did not ensure resident received food and water resulting in a change of condition. Per interviews with staff, staff stated that R1 was able to feed themselves until December 2025. 5 out of 5 staff deny that R1 was not provided with food and water. Per interviews with Executive Director John Goodwin stated that R1 was refusing food even with staff assistance around December 25, 2025 and hospice was notified. 6 out of 6 residents stated when they have received tray service they did not have issues receiving their food. It was alleged the Facility did not address change of condition. Per interviews with 5 out of 5 staff stated that all change of conditions are brought up to med-techs or management. Per interviews with staff, it was stated that R1’s hospice was notified when R1 was refusing food and then R1 was moved a few days after their change in condition. Therefore based on the preponderance of evidence through records reviewed and interviews the allegations Facility did not ensure resident was repositioned causing bruising ,Facility is charging for services not provided, Facility did not ensure resident received food and water resulting in a change of condition, Facility did not address change of condition in resident are determined to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies are being cited in today's visit. An exit interview was conducted and a copy of this report was provided.