complaint·December 17, 2025

1.) Staff sleep at the facility while on shift. It was alleged that staff sleep during their shift and that management has not taken any actions towards the issue. Interviews with residents stated that they have not observed staff sleeping while on duty in addition to interviews with staff members who denied the allegation. Interview with the WD, revealed that two (2) staff members have received disciplinary actions for sleeping while on shift within the last year. Based on the information provided by interviews and record review, the above allegation is deemed Substantiated at this time and is considered a technical violation. No citations are being issued at this time, as the facility took the appropriate measures. Exit interview conducted. A copy of the report and appeal rights were provided. Regarding the allegations: 1.) It was alleged that staff consumed alcohol during their shift at the facility, impairing their ability to provide adequate care and supervision. Interviews conducted with staff revealed inconsistent statements regarding the allegation. Interview with the ED denied the allegations. Interviews with residents did not reveal any concerns regarding the allegation. The LPAs had conversations with the ED regarding the allegation and explained the importance of maintaining appropriate staff conduct to ensure residents health and safety. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. 2.) It was alleged that staff members from the afternoon (PM) shift locked the residents in their rooms. Physical plant tours revealed that Memory Care (MC) rooms cannot be locked without the residents having the ability to unlock the door on their own. The Assisted Living (AL) rooms have individual keys for each resident and can also be unlocked from the inside. Per interview with the ED, the main entrance door locks at night from the outside, however, remains unlocked from the inside. Interviews conducted with staff denied the allegations of staff locking residents inside their rooms. Resident interviews did not reveal any concerns regarding the above allegation. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. 3.) Staff did not meet the residents' diapering care needs in a timely manner. It was alleged that residents in MC were left in soiled diapers as a result of MC staff sleeping during their shift. Interviews with WD revealed that once residents press their pendants for assistance, the wait time is approximately 7-10 minutes. Residents interviewed did not express concerns regarding soiled diapers. Staff interviews revealed that wait times vary depending on current tasks, but that they try to assist residents in a timely manner to ensure residents are not in soiled diapers. Staff interviews reveal that for MC residents, they check on residents every 2 hours. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.