complaint·February 3, 2026

Allegation “Staff yelled at resident:” The complaint alleges that on 01/01/2026, staff in the facility’s memory care unit was heard yelling at a resident from across the room. Interviews with both staff and residents revealed that the staff are nice and very caring. No staff nor resident interviewed has ever observed any staff being disrespectful, rude, or yelling at any residents. One resident indicated they believe the staff is excellent, friendly, and they care. Management did indicate that particularly in Memory Care, there are some more impulsive residents and that the staff keep a close eye on those residents for their safety. There have been occasions where a resident began to get up and the staff have called the resident’s name in an attempt to get their attention. The staff were trying to get the attention of a particular resident in a positive way, not anything such as yelling or disrespectful tone. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is deemed UNSUBSTANTIATED at this time. Allegation “Staff did not comply with infection control requirements:” The complaint alleges resident wheelchairs are left unsanitary with food and feces and the memory care kitchen area is left unsanitary. During the facility tour, LPA observed the facility kitchen, resident wheelchairs and LPA took photographs. The kitchen area appeared to be relatively clean and the kitchen area is inaccessible to residents in care. The facility does have an infection control plan, which was reviewed with facility staff in December 2025 during the facility’s staff meeting. Interviews revealed the facility is prompt in cleaning up any spills and taking action to ensure the facility remains clean and sanitary. Staff interviewed indicated that the protocol differs, depending on the cleaning and sanitization needed. If a resident is bleeding, the medication technician is called for assistance, and the med tech cleans up the blood before the housekeeping staff sanitize the area. In the case of urine or feces, the care staff will clean the resident and their wheelchair/chair if needed. If there is urine or feces on the floor, housekeeping staff clean and sanitize the floor. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C (p.3) Allegation “Staff did not protect food from contamination:” It was alleged that food is left out uncovered in the Memory Care kitchen area. LPA observed the memory care kitchen during the facility tour and did not observe any food left out on the counters. The facility has warming trays in the memory care kitchen, which were not being utilized at the time of the tour. Staff interviews revealed that food is prepared in the main kitchen area then delivered to the Memory Care unit. One (1) of the memory care staff puts the food into the covered warmers and plates the food for the residents. When residents are done eating, the plates are cleared, food is cleaned up, and the Memory Care staff return the cart, including all dishes and any remaining food, to the main kitchen. LPA observed some food in the refrigerator in the Memory Care unit, which was covered and labeled per regulation. Interview with staff and residents revealed no one has seen food left out in the Memory Care unit. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is deemed UNSUBSTANTIATED at this time. Allegation “Staff did not properly address roaches in the facility:” The complainant indicated roaches were observed in the Memory Care kitchen area, was reported to management, and was not addressed. Interview with staff revealed that there was one (1) person who indicated they saw a roach. Maintenance staff opened all the kitchen cabinets and drawers, looked behind the refrigerator and all other moveable items and did not observe any evidence of an infestation. The facility has a contracted pest control company that provides regular preventative service each month, which was last completed 01/28/2026. As a result of the report made to management regarding an observed roach, the pest company added an additional treatment (roach gel) for the Memory Care kitchen during the recent visit and noted on the report "no activity found inside while performing service." Interview with staff and residents revealed there have been no direct observations nor any evidence of pests in the facility. During today’s facility tour, LPA did not observe any evidence of pest infestation in the facility. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C (p. 4) Allegation “Staff did not ensure hazardous items were inaccessible to residents:” The complaint alleges that cleaning supplies and scissors were left accessible to residents in the Memory Care kitchen area and personal items have been left unlocked in resident rooms. During facility tour, LPA noted the Memory Care kitchen has a gate at the entry, which was observed to be latched shut. LPA did observe a pair of scissors in a drawer in the kitchen, but the kitchen area was inaccessible to residents. No cleaning supplies or hazardous personal items were observed accessible during facility tour. Management indicated that all grooming and hygiene items are locked, due to facility policy, but indicated that no residents are at risk if allowed access to these types of items. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is deemed UNSUBSTANTIATED at this time. Allegation “Staff did not allow residents to participate in planned activities:” The complaint alleges that particularly on Sundays and Mondays that the residents in Memory Care (MC) are not offered activities. LPA interviewed the facility’s activity staff for Memory Care, who works Tuesday through Saturday as well as the Memory Care Director who works Sunday through Thursday. Management indicated that when the activity staff is scheduled out, the Memory Care Director assists with activities, as do all care staff. LPA obtained a copy of the Memory Care activity schedule, which shows a variety of activities offered to residents throughout the day every day. There are activities in the Assisted Living (AL) side of the facility that Memory Care staff escort the residents to. Residents interviewed stated there are activities offered to those who choose to engage, but they are never forced to attend activities. Activities include but are not limited to: arts and crafts, exercise, puzzles, games, sing along, and religious services. Management did acknowledge there was a time recently when many Memory Care residents were ill and chose not to participate in the activities offered due to their illness. But typically, many residents do participate and seem to enjoy the activities offered. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C (p. 5) Allegation “Staff did not allow residents to attend religious services:” The complaint alleges that residents are denied mass on Sundays. LPA observed the activity schedule to include Catholic mass scheduled each Friday at 10:00AM. Additionally, there is a church service listed every Sunday at 03:00PM. Residents and staff interviewed indicated all residents in the facility, including those in the Independent Living, Assisted Living, and Memory Care are offered an outdoor church service on Sundays in partnership with Jubilee Church. Interviews revealed that there has never been a time when attending these services was denied. Additionally, residents are free to leave the facility with a family member at any time to attend other religious services of their choosing. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of today’s report was provided.