Facility Evaluation Report

On 9/03/2025, Licensing Program Analysts (LPA) Triel Ellen Lindstrom and Arielle Pascua arrived unannounced at the facility to deliver a case management deficiency. The LPAs met with Administrator Lacy Vincent (S1) and explained the purpose of the visit.

The department has recently conducted five visits to the facility on 5/5/25, 5/28/25, 6/9/25, 8/4/25 and 8/7/25. LPA’s Pascua and Lindstrom conducted interviews with fifteen staff, ten residents, and four family members. LPA Lindstrom interviewed S1 on 8/04/2025. During that interview, S1 stated that stafffing levels at the facility are based on the needs of the resident. S1 stated that the staffing ratio in Memory Care is one staff for every seven residents.

F1 stated that on 8/4/25, there was only one caregiver working in memory care with 28 residents and R1 was soaking wet in the bed. S2 and S5 state that when they are not sufficiently staffed, they are unable to give residents showers. R6 states that when the facility is not sufficiently staffed, it can take an hour for someone to respond to her when screaming and unable to reach her call button. R7 states that the facility is often not sufficiently staffed and that staff have to work overtime. R7 states that on 6/9/25, a resident had to go to the hospital and there was a delayed response to call pendants. R7 also stated that due to insufficient staffing, the staff don’t “spot” her when walking. On 5/29/25, S10 stated she was the only one working in memory care. The facility’s August work schedule shows that only 2 caregivers were working memory care in the AM shift on August 4 th ,28 th and 31 st and that there was only one caregiver in the AM shift on August 7 th , 13 th , 14 th , 19 th , 20 th , 25 th , and 26 th . Text messages from S7 stated that hiring more staff doesn’t happen overnight and that no one should tell Licensing that they are short staffed.