It was reported that there are residents with head wounds and blood running down them.

On 08/27/2026 LPA toured the facility and observed Resident 1 (R1) who has a Band-Aid on their forehead. There were no other residents who appeared to have head wounds.

LPA reviewed incident reports for the facility and found two reported falls for the month of July and three for August 2026. It was reported that R1 had an unwitnessed fall on 08/22/2026 and sustained a skin tear on their right elbow, bruising, a small laceration on chin and upper lip, and complaints of right foot pain. R1 was transported via EMS for evaluation.

During staff interviews it was learned that R1 has a band aid on their head because they pick on a scab and it bleeds.

ED stated On 08/03/3036 Resident 1 fell and hit their head. R1 had a scratch on their forehead and staff put a Band-Aid on it. Their POA was contacted and refused transport. On 08/22/2026 R1 had another unwitnessed fall. POA was contacted and agreed to send her out for evaluation.

It was determined that the facility has not had an unusual amount of falls during the months of July and august 2026. One resident did have two falls in August 2026 but they received appropriate care related to the falls. The resident has a small scratch that is covered with a band aid due to resident “picking” at the scab which causes it to bleed. This allegation is unsubstantiated.

Staff are not adequately assisting residents with activities of daily living. - UNSUBSTANTIATED

It was reported that a resident hadn’t been shaved and was wearing the same dirty clothes for days.

During visits on 08/27/2026 and 09/10/2026 LPA observed all residents to be appropriately dressed for the time of day.

During staff interview it was learned that resident’s clothes are changed every morning and at night before bed. Some residents refuse to change their clothing. Lots of male residents refuse to be shaved.

ED stated the male residents are shaved weekly if they don’t refuse. Resident’s clothes are changed daily.

It was determined this was submitted by an anonymous complainant who did not provide any details as to which specific resident this allegation concerns. This allegation is unsubstantiated.

It was reported that a resident was laying in their own feces.

During visits on 08/27/2026 and 09/10/2026 LPA did not observe any resident laying in feces.

All staff interviewed stated residents are toileted every two hours.

ED stated the residents are toileted as needed but at least every two hours.

This allegation is unsubstantiated.

Staff are not providing adequate food service to residents. - UNSUBSTATIATED

It was reported that the food was cold and staff do not offer meals to residents who are sleeping.

Staff interviews revealed if a resident is sleeping staff will try to wake them but if they don’t want to wake up their meal is kept hot until they are ready to eat. Staff takes meals straight from the kitchen to the rooms or residents right away. No plates are pre-made, they all come straight from the warmer. Most of the time the plates are warm as well.

ED stated meals are served first from the kitchen to table or to room. The meals don’t sit out. Staff make them plate by plate which takes time. They have a hot cart and anything that needs to be kept warm they will keep it in there while they are serving their plates. If a resident is sleeping staff try to arouse them and if they are not arousable staff put their plate aside and offer again when they are awake.

This allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to Executive Director Grace Hawkins.