It is alleged that the facility does not have sufficient staff to meet residents' care and supervision needs, particularly during the PM and night shifts, resulting in delays in resident care. During the investigation, LPA conducted interviews and facility visits during both daytime and NOC shift hours to assess staffing levels and resident care across different shifts. Staff provided varying information regarding staffing. Some staff stated that staffing is sufficient to meet residents' needs, while others reported that additional staff would be beneficial, particularly during the PM and NOC shifts. Staff stated that unexpected call-offs can result in residents waiting longer for assistance. Staff also reported that the facility utilizes registry staff when additional coverage is needed and is actively recruiting and hiring additional staff. During resident interviews, the majority of residents reported experiencing delays in care, particularly during the evening shift, and expressed that the facility appears to be short-staffed. Residents generally reported that staff eventually respond and provide the requested assistance; however, response times can be lengthy. LPA conducted observations during both daytime and NOC shift visits. During the NOC shift, LPA observed two caregivers assigned to Assisted Living and two caregivers assigned to Memory Care, with one medication technician monitoring the switchboard and resident call lights. LPA observed staff actively working and available to respond to resident needs. NOC staff interviewed reported that the shift is generally quiet, the workload is manageable, and the current staffing level is sufficient to meet residents' needs.

Allegation: Facility does not purchase diapers for residents.

It is alleged that the facility does not purchase diapers for residents, requiring family members to provide diapers while the facility primarily provides pull-ups. During interviews, staff stated that the facility manages residents' day-to-day incontinence supply needs based on each resident's individual circumstances. Some residents receive diapers automatically through their insurance, while some families choose to purchase diapers for their residents based on preference. Staff stated that when additional supplies are needed, the facility assists with obtaining diapers and maintains donated supplies for immediate use. During resident interviews, some residents stated that their families purchase their diapers, while others reported receiving diapers through their insurance and had boxes of supplies available in their rooms. Other residents stated that the facility assists them with obtaining diapers when needed. During the facility tour, LPA observed a supply room containing donated diapers in various sizes available for residents as needed.

(continued on 809C)

It is alleged that the facility has a roach infestation, with roaches observed in resident rooms, hallways, the cafeteria, elevator, and other areas of the facility. During staff interviews, multiple staff reported observing roaches in resident rooms, hallways, the elevator, and other areas of the facility. Maintenance staff acknowledged receiving complaints regarding roaches and stated that pest control services are conducted every Friday. During resident interviews, some residents reported observing roaches, while others stated they had not observed any.. During record review, LPA reviewed over six months of pest control treatment records from Orkin LPA also contacted Orkin and confirmed that weekly pest control services began in March 2026 and have continued as part of the facility's efforts to address and control pest activity.

Based on the investigation conducted, which included interviews with staff, witnesses, and residents, as well as a review of relevant records, there was insufficient evidence to support the reported 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 allegation is UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided.