complaint·December 12, 2023

CONTINUED...to provide feedback for staffing ratios for 2020 year. Eight of fifteen interviewees indicated having no knowledge of facility during complaint time-frame. Seven of fifteen interviewees indicated that staffing was challenging during COVID-19 pandemic due to staffing call offs, acuity due to COVID-19 pandemic and relying on Agency staffing. (ED) Galloway indicated “We are fully staff currently, however still actively hiring for back up/on call positions to fill in. We stopped using Agency staff effective 2/28/2023.” Scheduling records from February 2020 to June 2020 revealed that facility had 2-4 caregivers scheduled on AM shift, 2-3 caregivers scheduled on PM shift, and 2-4 caregivers on the NOC shift varying on Assisted Living and Memory Care Unit. Facility census at the time of complaint was 33 residents. During today's facility inspection visit, LPA Quiroz observed pull chords throughout the facility including hallways, bathroom areas and common living areas and resident bathroom areas. LPA Quiroz observed resident carrying pendants on their possession readily available to call for assistance when needed. Documentation review of Staffing schedules for November 2023 and December 2023 reveal facility is currently staffing the following staff in Assisted Living area: 3 caregivers, 2 shared medication technicians, shared Memory Care Director, and shared Resident Care Coordinator with memory care unit on AM Shift, 2-3 caregivers, 1 shared medication technician with memory care unit on PM shift and 1-2 caregivers and 1 shared medication technician with memory care unit on NOC shift. Documentation review of Staffing schedules for November 2023 and December 2023 reveal facility is currently staffing the following staff in Memory Care Unit: 2-3 caregivers, 2 shared medication technicians, shared Memory Care Director, and shared Resident Care Coordinator with Assisted Living Unit on AM Shift, 2 caregivers, 1 shared medication technician with Assisted Living Unitt on PM shift and 1-2 caregivers and 1 shared medication technician with Assisted Living Unit on NOC Shift. (ED) Galloway indicated that "a staff gross for 2024 budget has been approved, and will be implemented as census gross to continue to able to provide good quality care services to residents in care." Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation “Staff is not providing adequate care and supervision to the residents” is deemed Unsubstantiated. An exit interview was conducted with (ED) Galloway and a copy of this report was provided at exit.