Allegation: Facility illegally evicted a resident in care.

The complaint alleges that the facility issued R1 an eviction notice requiring him to leave by April 30, 2024, and threatened to call law enforcement if he did not comply. It was further alleged that the eviction was due to an unwitnessed fall.

During the June 30, 2026, interview at 1:30 p.m., the Licensee (A1) denied issuing any eviction or threat of eviction, stating instead that R1’s family wanted him to move because the facility was not a good fit.

W1, the former administrator, also denied the allegation. W1 stated that R1’s family chose to relocate him and provided DSS with a handwritten note from the POA dated May 1, 2024, stating that a new placement had been found. W1 additionally reported that the family raised financial concerns, as reflected in text messages between W1 and the POA.

Of the two staff interviewed, one denied that R1 was evicted and stated that the family located a new facility for him. The second staff member was new and could not provide relevant information. One staff member also reported that while R1 sometimes demonstrated aggressive behavior, he was never asked to leave. Staff denied that R1 experienced any falls while in care.

The Department reviewed the handwritten note from R1’s POA, the text messages referenced above, and the Admission Agreement (dated 4/19/23).

R1 was unavailable for interview, as he no longer resided at the facility and has since passed away. He was on hospice at the time of his death.

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Allegation: Staff did not properly feed a resident in care.

The complaint alleges that a staff member continued feeding R2 while she was choking.

On June 30, 2026, A1 denied the allegation, stating that there were no reports of choking involving R2.

Of the two staff interviewed, one stated that R2 was capable of feeding herself and had never experienced a choking incident at the facility. The second staff member was new and unable to provide information.

W1 also denied the allegation and indicated there were no reports of R2 choking during her stay.

The Department reviewed R2’s Physician’s Report (dated 1/2022), Resident Appraisal (dated 5/13/20), and Physician’s Certification for Hospice Benefit (dated 1/7/22).

On July 1, 2026, three residents (R3–R5) were interviewed. All three reported that they are treated well, have never been fed too quickly or in a manner that caused choking, and feel safe and cared for in the facility.

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Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Allegation: Staff restrained residents in care.

The complaint alleges that R1 was placed in a wheelchair with a belt to prevent him from slipping.

A1 denied the allegation, stating that R1 was never restrained, that he understands postural supports require a physician’s order, and that staff do not use restraining devices on any resident.

W1 similarly denied the allegation and confirmed his understanding of the requirement for physician authorization for postural supports.

Of the two staff interviewed, one stated that R1 never used any restraining device and did not use a wheelchair. The second staff member was new and unable to provide information.

On July 1, 2026, all three residents interviewed (R3–R5) stated that they have never been restrained and have never observed any resident being restrained at the facility.

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Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

There were no deficiencies cited during today’s visit. Exit interview conducted and copy of report provided.

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