complaint·August 6, 2025

Administrator stated the management team has hired new team members, including care and personnel staff. It was advised that all new hires are available for assistance on the floor as needed. Interview with Executive Director, Juanita Jackson disputed the allegation indicating there were no residents at the time of the complaint requiring a two person assist on either side of the facilities programs. Executive Director stated there are always sufficient staff scheduled for each shift. Interview with additional staff stated the facility utilizes the "Service Alignment" Program, which is a system which determines how many staff are needed pertaining to the residents that the facility has in care. Interviews with additional staff stated there are no concerns regarding sufficient staff. Staff also stated there were no concerns addressed by residents regarding wait times. Information obtained from interviews with residents stated there are no concerns or issues with staff responding to the call pendants or how many staff are available to assist. Interviews with additional residents indicated staff are present and available to assist with needs. LPA’s review of the records determined the program does indicate how many staff are needed per shift. LPA also reviewed “Labor Detail Report”, “Service Alignment Benchmark”, and the “Staff Sign-In Sheets” which revealed there were enough staff to provide adequate care and supervision to the residents in care on all scheduled shifts. Information obtained from additional witnesses indicated the Med-techs are extra back, the cooks, housekeeping team and the activities coordinator will each step in to assist if there is an issue or any concerns. Based on interviews, record review, and observations, the allegation that facility does not have adequate staff to meet the resident’s needs has been deemed unsubstantiated. An allegation determined unsubstantiated means although the allegation may have occurred there is not sufficient evidence to support the listed allegation. An exit interview was conducted. A copy of this report was explained and given to Licensee, Shemika Johnson.