Allegation 1: Staff does not ensure rodent issues are being treated properly for residents in care

On 9/9/2025, LPA conducted interviews with Residents 1- 11 (R1–R11). Resident 1 (R1) stated they have seen rodents in their room and reported that exterminators have visited the facility on several occasions to address the rodent concern; however, rodents continue to be observed in their bathroom and closet areas. Interviews with R2, R3, R4, R5, and R6 indicated that they have heard about rodents but have not personally seen them. Interviews with R7, R8, R9, R10, and R11 indicated that they have neither heard about nor seen rodents in the building.

LPA also conducted interviews with Staff Members 1- 6 (S1–S6). S1, S2, S3, and S4 stated that they have not seen rodents, but they have heard reports of rodents being in the building and Pest control have been at the facility to address the problem. Staff members 5-6 (S5- S6) stated that they have heard complaints about rodent sightings and have personally observed rodents in the facility. 6 out of 6 staff members confirmed that they have observed pest control services provided at the facility to address rodent concerns.

LPA also conducted a tour of the facility which consisted of the dining and kitchen area and LPA didn't observe any visible holes in the walls and nine (9) residents’ bedrooms 56,65,57,59,55,18,20, 25, and 16 and there were no visible bugs/pest during the inspection.

LPA also reviewed records from BugFree Central, Inc. work orders dated 8/14/2025, 8/27/2025, and Orkin Service contract dated 7/25/2025, and 8/22/2indicatenot indicated that (3) three of the resident’s rooms were treated only.

Allegation 2: Staff does not ensure residents’ bathing needs are being met.

On 9/9/2025 LPA conducted interviews with Residents 1- 11 (R1–R11). Residents 1-10 (R1-R10) stated they have received their showers on their scheduled shower days and if alternative measures are needed staff are willing to assist.

LPA also conducted interviews with Staff Members 1- 6 (S1–S6) and 6 out of 6 staff members stated that there are times when R1 is not willing to be showed at their scheduled time or R1 may even decline a shower all together, but caregivers offer at least 3 times before alternate days or times are adjusted. LPA also observed the resident shower schedule, log/notes which appear that R1 and other residents bathing needs are being met by the staff.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation 3: Staff does not ensure call buttons are answered in a timely manner

On 9/9/2025, LPA Allen conducted interviews with Residents 1–11 (R1–R11) and 1 out of 11 residents stated their call button does work but staff members take too long to assist them when called. When asked further, it was clarified that it can take staff too long to respond, which can take 15 minutes or longer when the call button was used.

LPA also conducted interviews with staff members 1-6 (S1-S6) and 6 out of 6 staff members stated that staff does ensure call buttons are answered in a timely manner. When asked how long the response time can be staff stated assistance normally happens between 5-10 minutes and if additional time is needed the receptionist is informed of the estimated time or another staff member is asked to assist. LPA observed the log for calls, and it appeared that staff members do respond to call buttons between 5-15 minutes

The facility’s call log, dated August 30, August 31, and September 1 through September 8, 2025, was reviewed and revealed that staff members have responded within 5-15 minutes. Call buttons in rooms 56, 65, 57, 59, 55, 18, 20, 25, and 16 were tested and found to be in working condition.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted where this report was discussed and provided to Administrator Nathaniel Venzon at the conclusion of the visit with appeal rights.