complaint·December 4, 2025

Per Executive Director, the management team had concerns that had been brought up to them regarding communication from S1 towards others. However, it was the staff that resigned and was not fired. Per documents reviewed S1 provided a resignation letter to the facility on 1/3/24 and their last day of employment was 1/24/24. 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. Regarding allegation: Facility does not follow their plan of operation. It is alleged facility did not have a plan to provide training to staff to deal with residents that have behaviors. Interviews conducted with residents revealed facility’s staff provide adequate care to the residents. Interviews with staff revealed staff receive 40 hours of initial training and throughout the year they complete their additional training yearly, including behavioral response training. Documents reviewed revealed in 11/7/24, 12/3/24, and 12/18/24, staff received training in the following topics: Psychosocial Needs of the Elderly, Takes a Village Other Side of the Mirror, Positive Therapeutic Interventions and Activities. 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 conducted with Shannon Moore and a copy of this report was provided.