The inspector noted the roach on the wall and, two minutes later, asked a dietary aide about it.
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That decision stood for eight days.
The call light was hanging from the bed rail on her right side.
The dates and times attached to entries were also off.
That is what triggered a complaint inspection at the facility at 6650 South Soncy Road on April 29, 2026.
The inspection, completed April 29, 2026, centered on a single resident identified in the report as Resident 1.
Federal health inspectors flagged Gardens at Stevens following a complaint investigation conducted on April 28, 2026.
That distinction matters in a regulatory sense.
The photo appeared on the cook's public social media page on March 30, 2026.
Inspectors did not find that residents had already been burned.
What followed was an investigation that ended with the facility concluding it could not substantiate sexual abuse.
Inspectors visited the facility on April 28 and 29, 2026, following a complaint.