complaint·November 25, 2025

Based on interviews conducted during this investigation, it was learned that this facility used to employ the services of a third party agency who provided temporary staff to serve as caregivers to this facility. This practice was utilized until the end of September 2025 when this facility finally decided to end the contract and no longer accepted any temporary caregivers from this agency. It was learned that this facility employed staff to cover 24 hours of care and supervision and broke the hours into three 8 hour shifts. These shifts were the AM, PM, and NOC shift. It was learned that in the Memory Care Unit there were 3 caregivers present at each shift with one dedicated Medication Technician as well. It was learned that the staff coverage was related to the overall resident census and would fluctuate if the census went down or go up if additional residents were admitted for care. Based on a review of the forms and documents provided, specifically the LIC 500, it was observed that the number of staff present for each shift did reflect the outlined numbers of 3 caregivers with one Medication Technician at this time. A tour of the memory care unit was conducted and it was observed that furniture, furnishings, and most items intended for resident use were observed to be maintained and able to meet the needs of the residents at this time. Based on a review of the forms and documents obtained during this investigation, it was learned that resident assessments were performed quarterly in order to address any changes to the needs and services that had to be updated with the residents. It was also learned that additional assessments and appraisals were performed when a resident was sent out to the hospital with new orders from their attending physician in order to address any new changes to their conditions. It was learned that these incidents of hospitalization or residents being sent out were duly reported to CCL within the allotted time frames. It was learned that any changes were then also reported to the resident, and their responsible parties, so that the change in level of care could be discussed at that time. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred. There were no deficiencies observed or cited at this time. Exit Interview