Complaint·July 13, 2021

On 4/19/21, LPA Sager interviewed the Executive Director at 3:35pm. LPA interviewed staff on 05/11/21 at 3:52pm; 05/13/21 from 2:47pm to 4:19pm; 05/21/21 from 9:38am to 5:28pm. LPA interviewed a family member on 05/14/21 at 3:17pm. LPA interviewed the Director of Nursing on 05/20/21 at 2:09pm. LPA reviewed the October 2019 staff schedule for the Summer House Memory Care. The schedule reflects there is one LVN assigned to each shift (a.m., p.m. and noc). There are two med techs for the a.m. shift. There are two med techs for the p.m. shift except for the dates 10/27/19 through 10/31/19 shows no med techs on schedule. There are two CNA staff for the a.m. shift except for the dates 10/4/19, 10/14/19, 10/28/19 shows one staff on schedule. There are two CNA staff for the p.m. shift except for the dates 10/01/19 and 10/02/19 shows no CNA staff on schedule; 10/3/19 through 10/06/19 and 10/31/19 shows one CNA staff on schedule. There are two CNA staff for the noc shift except for 10/3/19, 10/4, 10/11, 10/17, 10/18, 10/24, 10/25, and 10/31/19 shows one CNA staff on schedule. LPA reviewed the resident roster for Summer House Memory Care dated 10/31/19 which reflects a total of 19 residents. LPA reviewed a random sampling of six Summer House Memory Care health and wellness records. Five of the six residents are non-ambulatory, incontinent and need either complete toileting assistance or require additional time. Five of the six residents have Dementia and cannot leave the facility unassisted. One of the residents has a wandering behavior. Four of the residents need transfer assistance. Two of the residents need a two-person assist. Staff interviews revealed that during October 2019 there were at times not enough staff to care for all the memory care residents in Summer House Memory Care. Staff interviews revealed at times residents were left unattended while staff cared for other residents. Staff interviews revealed residents would attempt to get up on their own instead of waiting for staff assistance and then falls would occur. Staff interviews revealed two staff were not enough based on the needs of the residents. When staff called out sick, some staff had to work double shifts or would be the only staff on shift to care for the residents. A family member interviewed witnessed numerous times that residents who needed assistance had to wait while staff were helping other residents. The family member also witnessed having to wait for staff assistance to come to the room after pushing the call button several times. Information obtained from the Administrator and Director of Nursing states they had adequate staffing in the Summer House Memory Care in October 2019. Based on the information obtained during the course of the investigation, there is sufficient evidence to support the allegations that in October 2019 facility staff failed to meet the needs of the residents due to an insufficient amount of staff in the Summer House Memory Care. The above allegations are deemed substantiated. Deficiencies issued on 9099-D, exit interview was conducted with the Executive Director, and a copy of the report was provided via email for signature. Appeal Rights emailed.