It was reported that "Staff speak inappropriately in the presence of residents in care" as it was alleged that staff make inappropriate comments around residents. Interviews conducted with nine (9) staff and (5) five residents reflected that all individuals interviewed have never observed any staff speak inappropriately or make inappropriate comments in the presence of residents.

It was reported that that "Staff do not seek medical attention for resident(s) in a timely manner" and “licensee does not ensure that residents are adequately assessed” as It was alleged that Resident #1 (R1) and Resident #2 (R2) sustained falls between 02/16 and 02/20 and did staff did not conduct assessments, instead they assisted residents off the floor. It was further alleged that staff were not properly assessing residents prior to admission. Interviews conducted and records reviewed reflected that R2 was admitted to the facility on 02/23/2026 after sustaining a fall at home. LPA found no documentation indicating that R1 sustained a fall during the alleged timeframe. LPA also reviewed incident reports submitted to the Regional Office (RO) and found no reports involving falls for either resident or other residents in care. LPA's interview with nine (9) staff members regarding the facility's protocol after a resident sustains a fall revealed that when a resident is found on the floor, staff do not move the resident immediately. Instead, they notify the med tech, who promptly conducts an assessment. The resident is evaluated for any visible injuries or bleeding, their ability to move is assessed, and staff determine whether the resident hit their head during the fall. If there is a head injury, 911 is contacted immediately. If the resident denies pain and there are no apparent injuries, the resident's family is notified to determine whether they would like the resident to receive further medical treatment. Additionally, residents are monitored for 72 hours following a fall to observe for pain or any changes in condition. Staff also stated that both the resident's family and primary care provider (PCP) are notified of the fall. Staff reported that they have not received any concerns or complaints regarding the facility's response to resident falls. Further interviews revealed that the Resident Care Director (RCD) completes a comprehensive assessment before accepting or admitting any resident into the facility. If a resident's condition changes after admission, staff report their concerns to the RCD, who reassesses the resident and discusses any necessary revisions to the care plan with the resident's family. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation.

It was reported that "Staff do not accord privacy to resident(s) in care" as it was alleged that residents are not given privacy as confidential information is disclosed when medications are administered in common areas. LPA's interview with (10) ten staff and (5) residents reflected that medications are often administered in the dining room during scheduled medication passes. Staff stated that residents may receive their medications in the dining room or another location, depending on resident preference and the care plan. Staff and residents did not report that confidential medical information was disclosed or that residents were denied privacy during medication assistance. In addition, residents did not report any concerns of how medications were administered at this time. LPA interviewed the reporting party, who was unable to provide specific dates or times for the reported incidents. 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 violations did or did not occur, therefore the above allegation, “Staff do not accord privacy to resident(s) in care” is deemed Unsubstantiated at this time.

It was reported that "Licensee is accepting residents with higher level of care needs" as It was alleged that Resident #3 (R3), Resident #4 (R4), Resident #5 (R5), Resident #6 (R6), and Resident #7 (R7) should not be retained at the facility because they require one-to-one care and have health conditions requiring a higher level of care. LPA reviewed the records for each resident and found no documentation of prohibited health conditions that would preclude admission or retention at the facility. Interviews with ten (10) staff members indicated that prospective residents are assessed before admission to determine whether the facility can meet their care needs. Staff stated they review each resident's care plan upon admission and before providing care and communicate directly with residents regarding their care preferences, including medication schedules and daily routines. Staff further stated that if a resident's care needs increase, they notify RCD for reassessment and to discuss any necessary changes in the resident's level of care with the family. All interviewed staff stated they had no concerns regarding the facility's ability to meet the care needs of residents currently in care.

It was also alleged that licensee is not adequately addressing bed bug infestation at the facility. It was reported that the facility has been infested with bed bugs many times with little to no effort to do anything about it until it got so bad that almost all rooms were affected and it wasn’t until then that a pest control company was called to treat the rooms, but the bug infestation came back again. A review of invoices from Orkin Pest Control revealed that Orkin began providing services to address bed bug concerns at the facility on 09/30/2025. According to the service report, Orkin inspected all areas of the facility for signs of bed bug infestation and treated one (1) apartment, as well as all common areas. During a follow-up visit on 10/13/2025, Orkin conducted another inspection and found no evidence of pest activity at the time of service; however, treatment was still administered in certain areas. On 10/16/2025, Orkin again inspected the facility and found no live bed bug activity but proceeded with treatment. During a subsequent follow-up visit on 10/302025, Orkin inspected all areas and observed no signs of bed bug activity, yet preventive treatment was again provided. Finally, on 11/10/2025, Orkin conducted an additional inspection and reported no evidence of pest activity at the time of service. Interviews conducted with staff revealed that Orkin conducts routine monthly inspections and utilizes a bed bug detection dog to inspect resident rooms and common areas. Staff reported that, although minor remnants of previous infestations had occasionally been identified, no further spread had been observed. Staff further stated that when a suspected bed bug is identified, management is immediately notified to take appropriate action. Furthermore, resident interviews indicated that bed bugs had been present in the past; however, residents reported that staff responded promptly to the issue and ensured that affected areas were treated accordingly. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “licensee is not adequately addressing bed bug infestation at the facility”. Therefore, this allegation is deemed Unsubstantiated at this time.

It was further alleged that staff are not following infection control protocols as needed. It was reported that staff were not wearing gloves when administering medications to residents. Interviews conducted with staff revealed that gloves are worn when providing personal care to residents or when there is potential exposure to bodily fluids. Staff stated that gloves must be changed between residents and between tasks, followed by proper hand hygiene after glove removal. They further explained that gloves are removed immediately after completing tasks that require their use and that proper hand hygiene is performed, as gloves should not be worn unnecessarily outside of care activities. Staff also stated that gloves are worn when preparing food and assisting residents with feeding. During the interviews, staff denied failing to follow infection control protocols and demonstrated knowledge of the infection control policies and procedures required by regulation. Additionally, staff reported that gloves are worn during medication administration when required. However, they explained that gloves are not necessary when assisting residents with the self-administration of medication, provided that proper hand hygiene is performed before and after assistance. Staff further stated that they had not observed other staff members failing to follow glove-use protocols and denied witnessing staff not wearing gloves when glove use was required. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff are not following infection control protocols as needed”. Therefore, this allegation is deemed Unsubstantiated at this time.

No citations issued at this time. Exit interview conducted. Report was reviewed and copy provided.