complaint·June 22, 2025

The investigation revealed the following: Allegation: Staff not providing adequate services The allegation alleges that there is not enough staff to provide adequate services to residents. During the facility tour, LPA observed four (4) caregivers and a Medication Technician (Med Tech) in the Memory Care Unit. LPA observed caregivers providing assistance to residents, a caregiver in common areas interacting with residents and supervising residents, and the Med Tech was passing afternoon medications. During record review at the facility, LPA reviewed the Time Detail Logs for 10/03/2021, on the AM shift there were seven (7) caregivers and four (4) Med Techs, on the PM shift there were six (6) caregivers and three (3) med techs, and on the NOC shift there were four (4) caregivers and two (2) med techs. LPA reviewed Staff Training Logs and observed staff receive training regarding Assisting With Activities of Daily Living (ADLs). Additionally, LPA received and reviewed Resident R1’s Service Plan dated 09/28/2021 that states R1 requires stand-by-assistance with all grooming two (2) times a day, complete assistance with dressing two (2) times a day, and complete assistance with showering and bathing two (2) times weekly, and assistance with toileting and incontinence six (6) times per day. During interviews with Staff S1-S5, on 06/21/25 from 2:30PM to 4:15PM, were asked if there is enough staff on each shift to meet resident needs, four (4) out of five (5) stated there is enough staff to meet resident needs. During interview with Resident R1 on 10/12/2021 and additional interviews with Residents R2-R10, on 06/21/25 from 10:20AM to 1:29PM, were asked if staff meet their care needs, ten (10) out of ten (10) stated their care needs are met. 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 . Allegation: Facility in disrepair. The allegation alleges that the facility is in disrepair. During the facility tour, LPA observed the facility to be clean and in good repair. During record review, LPA reviewed Work Orders that have been submitted and completed from 05/01/2025 to 06/22/2025. During interviews with Staff S1-S5, on 06/21/25 from 2:30PM to 4:15PM, were asked if there is anything not working properly or not working in the facility, five (5) out of five (5) stated everything is working properly in the facility. Additionally, Staff S1-S5, were asked if the facility is in disrepair, five (5) out of five (5) stated the facility is not in disrepair. Staff S1 and S5, during interviews were asked how long a repair takes once a Work Order has been put in, two (2) out of two (2) stated repairs are made within 24-hours unless a part is ordered and then will take at the most 72-hours for the repairs to be made. Additionally, Staff S1 and S2 stated if the repair cost is estimated $1000 or above, the repair must be approved by corporate before the repair is done. During interviews with Residents R2-R10, on 06/21/25 from 10:20AM to 1:29PM, were asked if there is anything in their rooms not working properly, eight (8) out of nine (9) stated everything is working properly in their room. Additionally, Residents R2-R10 were asked if the facility was in disrepair, nine (9) out of nine (9) stated the facility is not in disrepair. 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 Resident Service Director, Stephanie Roldan , and a copy of this report was provided.