Complaint·November 9, 2022

The investigation revealed the following...regarding the allegation: Inadequate staffing to meet the needs of the residents. It’s being alleged that several residents state the facility is understaffed and when the resident’s outreach to the facility the need is ignored or answered in a delay time period.” During interviews with the residents, LPA interviewed 6 out of 58 residents in total. 1 out of 6 confirm the allegation. R1 states, “I think they are running on less staff from what I heard. I think yes, they don’t have enough staff.” R2 states, “yes, there are enough staff that work here. They are meeting my needs. I feel safe.” R3 states, “As far as the staff, I’m fine with the staff.” R6 states, “There are enough staff. I mean I don’t need that much but the staffing pattern is fine here. During interviews with staff, LPA interviewed 4 out of 40 in total. 2 out of 4 confirm the allegation. S1 states, “we have a staff shortage, but we have been hiring from an agency for every single shift.” S2 states, “I think so, yea. We do need more staff because sometimes there’s no help for the residents. Sometimes they need help in the dining room.” S3 states, “we can use more in the area of caregiving. Sometimes we are short staff but it’s not always and we have been using agency so it’s a big help.” S4 states, “we are using agency to fill in the vacancies. When we have agency there is enough. We just have to orient them on the resident’s personality or needs.” Regarding the allegation: Facility did not provide requested documents to resident's representative. It’s being alleged the facility failed to send an incident report involving residents. During interviews with the residents, 0 out of 6 confirmed the allegation. R1-R6 unanimously all agreed to not having experienced the allegation and was unable to provide any context related to the allegation. During interviews with staff, 1 out of 4 confirmed the allegation. S1 states, “I kept forgetting to send it. I called and stated that I didn’t forget about faxing it, but I have been taking care of the facility. S2-S4 unanimously all agreed to not knowing about the allegations and was unable to provide any context related to the allegation. During a record review, LPA observed invoices billed to the facility for the month of September and October for the use of a staffing agency. LPA observed agency staff filling in vacant shifts throughout both months. LPA observed Administrator fax a copy of an incident report and provided a copy of the fax confirmation to LPA which showed documents were sent to resident’s representative. Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated.