Complaint·February 20, 2025

On 02/20/25 from 10am-11am LPA conducted interviews with (S1-S4) regarding the allegation above, 4 of 4 staff interviewed denied the allegation above. Per 1 of 4 staff interviewed, the facility works with a registry/agency if there is a shift that needs to be covered. On 02/20/25 from 11:15 am to 12:45pm LPA conducted interviews with R1-R6, 4 of 6 residents denied the allegation above, 2 of 6 residents interviewed reported experiencing an un-witnessed falls in the past. 6 of 6 residents reported feeling safe when assisted by staff. On 02/20/25 LPA conducted a review of memory care staff time cards and schedules, LPA observed that there is a total of 42 memory care residents which are split into 4 groups daily. LPA observed memory care to have 6 staff for the morning, 4 staff in the evening shifts, and 2 staff for NOC shift. 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. Exit interviewed conducted, and a copy of this report was provided.