Complaint·January 23, 2026

Allegation: Staff are not providing adequate care and supervision to residents in care The allegation alleges that due to the lack of staffing, residents are dirty and do not receive assistance with showers, wheelchairs are not clean, and staff do not perform hand hygiene between assisting residents. During the facility inspection, LPA observed five (5) caregivers and two (2) nurses on during the AM shift. On the first floor, LPA observed residents involved in activities with the Engagement Assistants, while the Caregiver was assisting a resident in their room, and the Nurse was supervising a few residents in the sensory area. On the second floor, LPA observed 14 residents participating in an activity with an Engagement Assistant, six (6) other residents were in another activity area with an additional Engagement Assistant. LPA observed Caregivers going into residents’ rooms and providing assistance. LPA observed residents well kept in clean clothing and well groomed. LPA observed resident’s wheelchairs were clean. During record review, LPA received and reviewed the Staff Schedule and observed during the AM and PM shift there are five (5) caregivers and two (2) nurses scheduled. During the NOC shift there are two (2) caregivers and one (1) nurse scheduled. Additionally, LPA received and reviewed the Staff Assignment Sheet and observed Caregivers currently provide care to seven (7) to nine (9) residents. During interviews with Staff S1-S9, were asked if they feel there is enough staff on during each shift, nine (9) out of nine (9) stated yes, they feel there are enough staff on each shift. Additionally, four (4) out of nine (9) staff stated there are certain times when they could use an additional caregiver, mainly during the NOC shift, in the morning, and during meals. During interviews with Residents R1-R5, were asked if they feel there is enough staff on shift to provide care to residents, five (5) out of five (5) stated yes, they feel there is enough staff on shift to provide care. Additionally, one (1) out of five (5) stated they could use and additional caregiver on the first floor. Durning interviews with Residents Responsible Party’s W1-W5, were asked if they believe there are enough staff on each shift to provide care to the residents, five (5) out of five (5) stated yes, they feel there is enough staff on shift. Additionally, three (3) out of five (5) stated they believed they would benefit with adding an additional staff to assist. During record review, LPA received and reviewed the resident’s Shower Log for January 2026. LPA observed that residents are scheduled to be assisted with showering two (2) or three (3) times a week and one (1) resident daily. Upon review of the log, LPA observed staff sign-off of showered or refused, is consistent with the scheduled numbers of showers per week. During interviews with Staff S1-S9, were asked how often residents are assisted with bathing/showering, nine (9) out of nine (9) stated residents are scheduled to be assisted with bathing 2 to 3 times a week. During interviews with Residents R1-R5, were asked how often they are assisted with bathing, five (5) out of five (5) stated they are assisted with showering at least two (2) times a week. Durning interviews with Residents Responsible Party’s W1-W5, were asked how often their resident is assisted with bathing, five (5) out of five (5) stated they are scheduled at least two (2) to three (3) times a week for a shower. Additionally, five (5) out of five (5) stated they do not have any concerns regarding their residents not receiving showers. LPA received and reviewed the Maintenance Daily Task Schedule that indicates wheelchairs are power washed on the last Wednesday of every month. During interviews with Staff S1-S9, were asked if residents wheelchairs are cleaned, nine (9) out of nine (9) stated yes, wheelchairs are wiped down with sanitizing wipes when a resident is transferred out of it or when they have an accident or spill something. Additionally, nine (9) out of nine (9) stated they are power washed and dried monthly. During interviews with Residents R1-R5, were asked their wheelchairs are cleaned, two (2) out of five (5) stated yes, their wheelchairs are cleaned and sanitized regularly. Additionally, three (3) out of five (5) residents do not require a wheelchair. Durning interviews with Residents Responsible Party’s W1-W5, were asked if their residents wheelchairs are clean, four (4) out of five (5) stated yes, their residents’ wheelchairs are kept cleaned. One (1) stated their resident does not require a wheelchair. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . LPA did not observe or cite any deficiencies. An exit interview was conducted with Administrator Christina Hale and a copy of this report was provided.