complaint·November 1, 2023

During record review, AGPA observed a text message on 1/21/22 between S3 and the scheduler from registry agency confirming two registry staff are being sent to work at the facility in the AM shift and five staff in the PM shift for 1/22/22. Registry agency responded and confirmed it was correct the following day. AGPA observed a text a couple minutes after confirming that the five registry staff for PM shift are actually scheduled on Sunday, 1/23/22, but the two registry staff in the AM were are willing to work double shift. However, interview with S1 revealed that the facility made multiple efforts to obtain staffing by contacting facility staff and registry agencies to obtain additional staffing for coverage. S1 stated staff from assisted living covered during the transition until another staff and S1 arrived to the facility. Allegation: Facility is making false claims about caregiver to resident ratios. However, LPA reviewed a sample of 5 residents records during January of 2022 and 5 of 5 residents did not require 1 on 1 care. Interview with S1 and S2 revealed that if there were issues with coverage, the facility will go through registry staffing to provide the coverage needed., Allegation: Administrator is not adequately performing required duties. However, based on interview and record review, during the COVID-19 outbreak, staff and Executive Director were in communication with each other to address any staffing issues. Allegation: Facility is not carrying out planned activities. Based on interview with staff and residents, when there was a COVID outbreak, activities were being delivered to residents rooms during isolation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided to Executive Director.