complaint·May 16, 2025

The investigation revealed the following: Allegation: Licensee does not ensure that there are enough staff to meet the needs of residents in care. The allegation alleges that staff have left and there are not enough staff to meet the needs of residents. During the facility inspection, LPA observed four (4) care providers, and the Activity Director working in the fourth floor Memory Care Unit, four (4) care providers working in the third floor Memory Care Unit, and four (4) care providers working on the Assisted Living floors. Additionally, LPA observed two (2) medication technicians working. LPA observed staff assisting residents to the rest room, during activities, escorting to meals, and assisting with eating. During record review, LPA received and reviewed the facility’s Staff Schedule from April 27, 2025, through May 17, 2025. LPA observed on the AM shifts, 6 AM to 2 PM, there are 4 Care Providers in Assisted Living, 3 Care Providers in the Memory Care Unit on the 3rd floor, 4 Care Providers in the Memory Care Unit on the 4th floor, 2 Med Techs, and 1 LVN. LPA observed on the PM shifts, 2 PM to 10 PM, there are 4 Care Providers in Assisted Living, 3 Care Providers in the Memory Care Unit on the 3rd floor, 4 Care Providers in the Memory Care Unit on the 4th floor, 2 Med Techs, and 1 LVN. LPA observed on the NOC shifts, 10 PM to 6 PM, there are 2 Care Provider in Assisted Living, 2 Care Providers in Memory Care 3rd floor, 2 Care Providers in Memory Care 4th floor, and 1 Med Tech . The Health Service Director (S3), who is an LVN, is scheduled to work Sunday through Thursdays from 9 AM to 5 PM. During review of the Positions/Work Hours/Shifts, LPA observed The Health Service Director is on call and available 24/7. During interviews with Staff S1-S11, were asked if they feel there are enough staff on each shift to meet the needs of residents, eleven (11) out of eleven (11), stated yes there is enough staff to meet the needs of residents. Additionally, Staff S1-S11 were asked how many resident’s care providers are assigned to assist during their shift, ten (10) out of eleven (11) stated care providers are assigned five (5) to seven (7) residents to assist. During interviews with Residents R2-R8, were asked if they feel there is enough staff on each shift to assist residents with care needs, six (6) out of seven (7) stated yes, there is enough staff on each shift to assist residents with care needs. Additionally, during interviews with Residents R2-R8, were asked if they receive assistance when needed, seven (7) out of seven (7) stated yes, they received assistance when needed. During interviews with Resident’s R9 and R10’s Responsible Party W1 and W2, were asked if there is enough staff on each shift to meet the needs of residents, two (2) out of two (2) stated yes, there is enough staff to meet the needs of residents. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . During today’s visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Joe Saldana, and a copy of this report was provided.