complaint·November 19, 2025

The investigation revealed the following: Allegation: Staff do not ensure residents room is good repair. It is being alleged that the bathroom in R1's bedroom has a leak and has a loose toilet seat. On 11/13/25 from 9:00 am- 11:50am LPA conducted Interviews with R1-R10 regarding the allegation above. 10 of 10 residents interviewed denied the allegation above, 7 of 10 residents interviewed reported that repairs happen right away, 2 of 10 residents interviewed reported repairs take a few days. On 11/13/25 LPA conducted interviews with S1-S6 regarding the allegation above. 6 of 6 staff interviewed denied the allegation above, 4 of 6 staff reported repairs happen same day, 2 of 6 staff reported repair time depends on what needs to be repaired. On 11/13/25 and 11/19/25 LPA conducted a tour of 10 bedrooms, LPA did not observe any disrepair's. Allegation: Staff do not ensure residents room is kept in clean sanitary conditions. It is being alleged that trash cans in resident bedrooms are not being emptied, and meal trays are not being removed from bedrooms which is causing mold. On 11/13/25 from 9:00 am- 11:50am LPA conducted Interviews with R1-R10 regarding the allegation above. 10 of 10 residents interviewed denied the allegation above and reported that trash cans are emptied out daily, and denied observing any mold in their bedrooms. On 11/13/25 LPA conducted interviews with S1-S6 regarding the allegation above. 6 of 6 staff interviewed denied the allegation above, 6 of 6 staff reported rooms are cleaned daily or as needed, 6 of 6 staff interviewed denied observing any mold in resident bedrooms. On 11/13/25 and 11/19/25 LPA conducted a tour of 10 bedrooms, LPA observed bedrooms actively being cleaned, LPA observed trash being removed, sweeping, mopping, and laundry service taking place. On 11/19/25 LPA conducted a review of the housekeeping schedule, LPA observed that each housekeeper cleans a 5-7 rooms each every day. Deep cleanings occur on Thursdays. LPA observed some bedrooms get cleaned more than once a week. Allegation: Staff do not ensure facility is kept free of pests. It is being alleged that the facility has a mosquito and cockroaches issue that is not being addressed. On 11/13/25 from 9:00 am- 11:50am LPA conducted Interviews with R1-R10 regarding the allegation above. 7 of 10 residents interviewed denied the allegation above, 3 of 10 residents interviewed reported seeing cockroaches in the past. On 11/13/25 LPA conducted interviews with S1-S6 regarding the allegation above. 6 of 6 staff denied the allegation above. 6 of 6 staff interviewed reported that if pest is observed or reported, pest control will be contacted and scheduled to treat the facility. On 11/19/25 LPA conducted a review of the Impressive extermination invoices for September 2025, October 2025 and November 2025. Per invoices, Impressive extermination treats the facility 2 times a month, the facility is treated more if any reports of pest have been submitted. On 11/13/25 and 11/19/25 LPA conducted a tour of 10 bedrooms, LPA did not observe any pest, LPA observed patio doors to be closed. Allegation: Staff do not ensure incontinence care needs are being met for resident. It is being alleged that facility staff are not assisting resident in care with changing soiled diaper resulting in resident being left in the same diaper for the entire day. On 11/13/25 from 9:00 am- 11:50am LPA conducted Interviews with R1-R10 regarding the allegation above. 4 of the 10 residents interviewed denied the allegation above, 6 of the 10 residents interviewed reported they do not require incontinence care. On 11/13/25 LPA conducted interviews with S1-S6 regarding the allegation above. 4 of 6 staff interviewed denied the allegation above, 2 of the 6 staff interviewed confirmed the allegation above and reported that sometimes residents are left in a soiled diaper due to shift exchange. 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 conducted, and a copy of this report was provided.