complaint·December 12, 2023

It was learned that often on NOC shift, there is only one caregiver and one medication technician to assist residents on the Memory Care building which hold approximately 60 residents at a time. Often, they are asked to ask another Medication Technician to come help their building out but will leave only one caregiver on the other side, which approximately holds 50 assisted living residents. It was reported that on some weeks during the AM and PM shift that they will only have 2 caregivers due to call outs. On 11/30/2023, LPA conducted an unannounced facility visit. During this visit, LPA observed 2 medication technicians’ clock in at 5:00am to the memory care building. Prior to the 2 medication technicians clocking there was only 1 medication technician and 1 caregiver. It was learned through that during this shift, 1 medication technician was called in at 2:30am because there was only 1 caregiver on site at the time. In a separate building, LPA observed 1 medication technician who also performed care giving duties for approximately 50 residents. A review of facility documentation was conducted. LPA reviewed 22 random resident files from the facility. Based on document review, it was observed that 17 out 22 residents were non-ambulatory, and 20 out 22 residents need hands on or one-on-one assistance one of the following items: grooming, bathing, showering, travel to and from meals and activities, and medication management. Upon further document review, it was found that approximately 10 residents need two person assists to help fully assist them to reposition, standing, turning or mobility needs. It was reported by staff that they could not help residents who are two person assists due to helping other residents who need immediate attention. It was stated that staff have resorted turning residents with their bedding and pulling them up from headboard to help alleviate residents needs. Additionally, it was reported that due to the lack of staffing, the residents are having later meals, showers are not being provided as scheduled, and medications are not provided on time and it takes approximately more than 15 minutes to respond to a resident. Based on the information gathered during the course of this investigation, the facility is not adequately staffed to meet the needs of the residents in care. Based on observations, review of records and information gathered through interviews, the above allegations were SUBSTANTIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged. An exit interview was conducted, a copy of the LIC9099, LIC9099-C, 9099-D, and appeals rights was provided to the facility at the end of this visit.