complaint·June 19, 2025

Investigation revealed the following: Allegation: Licensee does not ensure that the facility has enough staff to meet the needs of residents in care . The complaint alleges that R1 was walking towards the front door when R1 lost balance and fell to the ground and facility staff was unable to lift R1 to R1’s feet, staff then called 911 for assistance. Facility staff allegedly told the paramedics that “they do not have enough staff to lift someone.” On 4/11/25 at 9:45am, LPA interviewed Administrator (A1) who denied allegation and stated that the facility has sufficient staff to meet residents’ needs. On 4/11/25 between 10:45 am and 12:00pm, LPA interviewed 5 staff (Staff #1-5) and Assistant Administrator (A2) regarding the allegation; 5 out of 5 staff and A2 denied the allegation and reported that there is enough staff to meet the needs of the residents. On 6/19/25 during subsequent visit, between 1:00pm and 2:00pm, LPA interviewed 3 staff (S6-S8); 3 out of 3 staff interviewed denied allegation and reported that they never told paramedics that “they do not have enough staff to lift someone” as mentioned in the complaint. 3 out of 3 also stated that there is enough staff to meet the residents needs. On 4/11/25 between 1:00pm and 2:00pm, LPA interviewed 5 Residents (Residents #1-5). Of the 5 Residents interviewed, 5 out of 5 denied the allegation. 5 out of 5 stated that their needs are taken care of and that there is enough staff to meet their needs. On 4/11/25, LPA observed sufficient staff present at time of visit. On 4/11/25 and 6/19/25, LPA obtained, reviewed, and evaluated staff schedules and resident roster (current and week of incident) and found that sufficient staffing is maintained at the facility to meet the residents’ needs. Based on the information gathered, there is insufficient evidence to support the stated allegation Page 2 of 3 Allegation: Staff did not provide assistance to resident in care as necessary. The complaint alleges that when R1 lost balance and fell while entering the building, staff refused to assist R1 from the ground and stated that “it is not their policy to lift people up.” On 4/11/25, LPA interviewed Administrator (A1) who denied the allegation and stated that according to their policy, when a resident has fallen and can’t get up, they don’t move them because the extent of the injury is unknown. A1 further stated that for the safety of the resident and the staff, we do not move them, we call the paramedics who can better assess the situation. Consequently, if the resident can get up we then aid them by offering a chair to use as leverage to assist them in getting up. On 4/11 /25 between 10:45 am and 12:00pm, LPA interviewed 5 Staff (Staff #1-5) and Assistant Administrator (A2) regarding the allegation; 5 out of 5 staff and A2 denied the allegation, stating that staff assist residents when it is safe to do so. On 4/11/25, LPA obtained, reviewed and evaluated a copy of the Assistance with Transfer and Ambulation policy (dated 3/6/25) which provides guidance to caregivers regarding lifting resident--it states that Caregivers are not to lift a resident who has fallen and appears to be injured, due to the risk of injury to both the resident and Caregiver(s) involved. On 4/11/25, LPA also obtained and reviewed a copy the facility’s fall policy (dated 3/6/25). On 4/11/25 between 1:00pm and 2:00pm LPA interviewed R1-R5 and of those interviewed 5 out of 5 stated that staff assists them when needed. R1 stated that R1 had a recent fall and staff helped immediately, by calling 911 because R1 was unable to get up. Based on the information gathered, there is insufficient evidence to support the stated allegation. Although the allegations above 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 allegation are UNSUBSTANTIATED . There were no deficiencies cited during today's visit. Exit interview conducted and report provided to Jenni Gordon, Administrator Page 3 of 3