complaint·February 26, 2026

On 07/02/25, LPA collected electronic incident reports from the facility which are documented in the facility’s electronic health record (EHR) system. Dates of reports reviewed were from 01/02/25 to 07/02/25. LPA reviewed a total of 133 incident reports from the EHR. Based on this review and comparison to reported incidents submitted to the Community Care Licensing (CCL), LPA observed that falls described as having no visible injuries, minor skin tears, or no complaints of pain were not submitted to the Department. However, all serious incidents involving residents—such as falls resulting in pain, head injuries, or requiring transfer for medical attention—were reported to the Department prior to this complaint. While some fall incidents were not provided to licensing, regulations require that “a written report shall be submitted to the licensing agency… of any of the events specified in (A) through (D)… (A) Death… (B) Any serious injury… (D) Any incident which threatens the welfare, safety or health of any resident…” LPA interviewed staff on 7/2/25, 11/21/25, and 12/8/25 there were no reports of management directing staff not to report an incident. Of those interviewed all stated, they have no knowledge of management directing staff not to report incidents, falls, or injuries. Based on records, interviews, and observations there is not a preponderance of evidence to prove the above allegations did or did not occur therefore the allegations are UNSUBSTANTIATED at this time. On the allegation: Facility has insufficient staffing to meet the needs of the residents It was alleged that the facility has insufficient staffing to meet the needs of residents and that managers have recently covered a 24-hour shift. LPA conducted eight staff interviews and five resident interviews, and reviewed facility records. On 07/01/25, a former staff member reported that at times only one caregiver was present in Memory Care, although two caregivers and a medication technician are expected. On 07/02/25, the administrator acknowledged being down six to ten staff but stated shifts were covered by agency caregivers, managers, and current staff, and that the facility maintained required staffing ratios. Continue on 9099-C During the same visit, staff confirmed at least two caregivers per shift and denied managers working full 24-hour shifts. LPA reviewed schedules and timecards which showed that consistently there are at least two caregivers, if not three in the memory care unit and assisted living unit during daytime shifts, including a medication technician for each side and at minimum three total caregivers and one medication technician to cover the full facility during the NOC shifts. Resident interviews conducted on 7/2/25, 7/16/25, and 11/21/25, revealed occasional comments from residents indicating that staff claimed to be short-staffed when delays occurred; however, these statements were inconsistent and not corroborated by other evidence. Residents acknowledged the use of agency staff and noted that turnover affects consistency, but independent residents reported that there have generally been enough staff to meet their needs. Some residents and staff agreed that evening shifts are busier due to more residents requiring cognitive support. While some delays were reported, there is insufficient evidence to conclude the facility failed to meet care and supervision requirements during the time frame leading up to this complaint. Records indicate the facility has not violated staffing regulations during the time frame of this complaint. Based on interviews and record reviews, there is insufficient evidence to support the allegation that the facility is not adequately staffed to meet resident needs. While the allegations may or may not have occurred, the allegation is deemed UNSUBSTANTIATED at this time. A copy of this report was printed and provided to the administrator.