complaint·August 28, 2025

Continued from LIC9099... Review of Resident Council Meeting Minutes indicated that residents attending had no comments regarding Resident Care/Nursing. Seven (7) of twelve (12) residents interviewed stated they have not experienced or heard of other residents waiting longer then ten (10) minutes for help after call button activation. Over the course of the investigation, LPA observed receptionist calling out alerts for both MC and AL they received to caregiver over radio. Call outs consisted of specific location of the alert or specific resident calling if alert came from a resident specific pendant. Callouts were repeated until a caregiver responded. LPA did not witness any call out go unanswered for longer than ten minutes. LPA opened an alarmed door to the outside and a caregiver came within five minutes to check. Staff are leaving the residents unattended – Complainant alleges residents have been left unattended during clear moments of need and that staff are often unable to meet the needs of the residents due to understaffing. During this investigation LPAs made observations, reviewed records, and conducted interviews. Four (4) of twelve (12) residents interviewed stated they felt or heard concerns from other residents that facility was understaffed on certain days. Four (4) of five (5) staff interviewed felt they were overworked and in need of more staff. Eight (8) of twelve (12) residents interviewed stated they did not have any concerns with understaffing and staff are attentive to their needs. Review of staff Memory Care (MC) and Assisted Living (AL) staff schedules for July and August indicated sufficient staffing for resident care. LPA observed 12 residents in MC first floor main room with six (6) staff rotating care and two (2) dedicated staff leading activities. LPA observed ten (10) residents in MC second floor main room and five (5) caregivers. Administrator stated there are currently no residents on 1-on-1 care plans and facility has started to back hire staff to fill in for callouts. Administrator stated all MedTech positions are hired as dual MedTech/caregiver positions and are trained accordingly. Based upon observations, interviews, and record review we have found that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations/complaint is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.