complaint·March 6, 2023

(CONTINUED FROM FORM LIC9099) During the visit, LPA toured the two levels of the facility again and observed staffing levels to be in accordance with documented staffing goals for the facility. Records reviewed included past schedules which demonstrated adequate staff coverage for the three daily shifts. An additional tour of the physical plant was conducted on February 3, 2023 as part the complaint investigation referenced 22-AS-20230131162326. HVAC units were all observed to be functional at that point and temperatures were observed. A final facility visit was conducted on March 6, 2023. A tour of the physical plant was conducted and eight staff interviews were conducted by LPA during the visit. Regarding the allegation that Facility heater units are in disrepair, the following was concluded: At some time towards the end of Summer 2022 and the beginning of Winter 2022, multiple staff stated in interviews that individual heater units were dysfunctional and were temporarily replaced by electric floor heaters that had been ordered by the previous leadership team. Upon conducting the initial inspection visit, LPA was informed by the new leadership team that repairs were under way and have now been completed. Individual units are observed to be functional at the time of the present visit. A majority of accounts confirmed the statement, therefore the allegation is deemed to be Substantiated, meaning the preponderance of evidence standard has been met. Regarding the allegation that Facility is operating without an Administrator, the following was concluded: Around Thanksgiving 2022, the former executive director held an all-hand meeting to informally announce to staff the possibility that she might leave the facility. Over the following weeks, both the Executive Director and the previous Wellness Director became increasinly prone to being absent from the facility without HR or front desk staff being informed. No official notice of a last day at the facility or notice of delegated administrator responsibilities were issued by the licensee, leaving facility staff to improvise procedures to keep major facility functions operational. This lasted for several weeks until the current administrator was hired and onboarded on December 19, 2022. A majority of accounts confirmed this version of events, therefore the allegation is deemed to be Substantiated, meaning the preponderance of evidence standard has been met. Two citations were issued on an attached form LIC9099-D. An exit interview was conducted and a copy of this report along with appeal rights were provided to facility representative. During the visit, LPA toured the two levels of the facility again and observed staffing levels to be in accordance with documented staffing goals for the facility. Records reviewed included past schedules which demonstrated adequate staff coverage for the three daily shifts. An additional tour of the physical plant was conducted on February 3, 2023 as part the complaint investigation referenced 22-AS-20230131162326. A final facility visit was conducted on March 6, 2023. A tour of the physical plant was conducted and eight staff interviews were conducted by LPA during the visit. Regarding the allegation that Staff are insufficient in numbers to meet resident needs, the following has been concluded: Starting with the leadership team transition period in November/December and disruption in the chain of communication for staff calling out, difficulties with staffing occurring more often, causing staff to have to stay on overtime to ensure coverage goals were met. Additional hires were implemented to progressively remedy the amount of private agency staff the facility had to rely on. Multiple reviews of clock-ins and schedules demonstrated that the minimum targeted amount of staff were present at the facility. The allegation is therefore found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided and left at the facility.