complaint·March 24, 2026

9099C-1.. The Administrator, VP and Business Office Director stated that on March 24, 2026 that in January, 2026 and February 2026, there were (6) staff scheduled on the "am" and "pm" shifts. Specifically, there was (4) caregiver staff, (1) Med-Tech and (1) Nurse. During these same months on the NOC shift, there were a total of (3) staff scheduled, consisting of (2) caregiver staff scheduled and (1) Med-Tech. Starting on March 1, 2026, there were (5) staff scheduled during the "am" and "pm" shifts. Specifically, there were (3) caregivers, (1) or (2) Med-Techs and up to (1) nurse. For the NOC shift, there are (2) caregivers and (1) Med-Tech. In additional to the scheduled staff, the Administrator, Business Office Director, Activities staff and the VP are available to offer care assistance if needed. One caregiver stated on March 24, 2026 that there were currently (3) care staff working during the "am" shift today and that it there were more staff, it would be "better", but staff and managers will step in "right away" when called or if a resident needs immediate assistance. The caregiver confirmed that Med-Techs will assist with getting residents up and dressed in the morning, which is helpful. A second caregiver stated on March 24, 2026 that depending on the day,(3) caregivers is sufficient but on other days, (4) caregivers are needed and indicated that Med-Techs, nurses, managers and activity staff will sometimes assist when called for help. This staff stated it's easier to provide care on days where there are less showers scheduled. On March 24, 2026, LPA observed (27) residents present and most attending a morning activity when touring and multiple staff to be present assisting with the activity. LPA reviewed staffing schedules from January through March observed the schedules to reflect the above staffing levels. LPA reviewed shower documentation for (3) clusters and observed there to be both "am" and "pm" showers, including some residents receiving them through hospice; however some days had more showers scheduled than others. A manager stated "showers are consistently being given" but not all caregivers are completing the "Shower Review" documentation. The facility is in the process of changing from paper to electronic documentation. LPA was provided with a list of residents who received a shower from non-caregiver staff in February 2026 and March 2026. There were (14) showers given in each month to assist caregivers. Based on information obtained, the allegation is found to be UNSUBSTANTIATED- means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, *cont on 9099C-2 ... 9099C-2.. Allegation: Staff are unable to meet the transferring needs for the residents. The allegation states on many shifts, there are not enough caregivers to safely assist residents who require two person transfers or mechanical lifts (Hoyer). Documentation was reviewed showing there were (4) residents who needed assistance with a Hoyer Lift in January 2026 and February 2026, and starting in March 2026, there are (3) residents who were in need of this assistance. LPA observed the (4) residents to reside in three different clusters and the (3) to reside in (2) different clusters. Both caregiver staff stated that there are (3) to (4) residents that need a two -person assist or assistance with a Hoyer Lift, staff will "radio" for a second staff to help, and (1) staff caregiver stated staff will usually respond immediately. A second staff stated that the Med-Tech or nurse will "sometimes help, if they can", and activity staff leave their shift around 6:30 pm- 7:00 pm, so they cannot help after that time. A manager stated prior to March 1, 2026, there is a "floater staff" that helps with care and activities from 9:00 am- 6:00 pm. Both staff stated they preferred when there are more caregivers scheduled on the "am" and "pm" shifts. The administrator stated the March schedule was posted on February 27, 2026, and staff were notified during a meeting, 30 days prior to the staffing changes due to resident census. Based on information obtained, the allegation is found to be UNSUBSTANTIATED- means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, Allegation: Staff do not provide adequate food service . The allegation states there are multiple residents who require full feeding assistance during meals, which makes it extremely difficult to ensure all residents are fed safely and adequately. Managers stated there are (4)residents that need feeding assistance. One of the resident's family member(s) assist at every lunch and dinner, by choice. Additionally, there are always (2) caregivers present in the dining room with the residents who need assistance, and additional staff will step in and assist, including managers, Med-Techs, nurses and activities staff. *Cont on 9099C-3.. 9099C-3.. LPA toured both dining room during lunch on March 24, 2026 and observed residents who were independent with eating to be dining in one room and those needing assistance with feeding to be dining in the second room. LPA observed (1) resident to be receiving feeding assistance from their family member, and (3) other residents receiving feeding assistance from (2) different staff, a Med-Tech and an activities staff. Both caregivers interviewed indicated that Med-Tech and activity staff will assist (2) caregiver staff with feeding residents in the dining room when needed. One caregiver stating "sometimes two staff is enough" as she can assist with feeding (2) residents at a time. This caregiver commented that before there were (2) caregivers in each dining room, but now there are (2) caregivers in the dining room with more dependent residents and (1) caregiver in the dining room with more independent residents. Both caregivers confirmed that if they ask other staff to assist, they will. Managers stated that when the census increase, staffing levels will be re-evaluated and adjusted, if needed. Managers confirmed that there were (3) residents who frequently request room service and refuse to go to the dining room for meals. Staffing levels appear adequate based on the current census. Based on information obtained, the allegation is found to be UNSUBSTANTIATED- means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, Exit interview. Copy of report provided.