Complaint·March 20, 2025

In addition, all staff interviewed stated that when they observe any supplies to be low they inform either the med techs or management. All staff indicated that they have observed supplies to be ordered in a timely manner at this time.  During a physical plant, the LPA found a proper supply of these products in seven (7)   resident rooms in assisted living  and four (4) randomly selected bedrooms in memory care, as well as in a supply closet next to the med room and a storage room on the 2nd floor. Interviews with four (4) families / responsible parties of residents in care revealed that they did not express any immediate or potential  concerns for lack of supplies for residents at this time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff do not re-order incontinent supplies timely resulting in residents not having incontinent supplies” is deemed Unsubstantiated at this time. It was reported that "Due to lack of staff, residents are developing pressure injuries" as it was alleged that that there have been multiple shifts with only one (1) caregiver to assist all the residents. Interviews with eight (8) staff members indicated that seven (7) have never observed a shift with only one (1) caregiver. One (1) staff member reported that, on one occasion in the past year, they worked a shift with no other caregiver for approximately two (2) hours due to staff calling out. However, during this time, they received assistance from medication technicians and at least two (2) staff members from management until additional staff were called in. LPA's  review of staff schedules showed that, typically, there are at least three (3) caregivers scheduled per shift, and on heavy shower days, four (4) caregivers are scheduled. During the NOC (night) shift, there are (3) caregivers on the floor, along with a med tech and a nurse on call. Additionally, interviews and records review revealed, that five (5) residents have been observed with pressure injuries since November 2024, but all were seen by home health or hospice care at least twice a week. Furthermore all staff indicated depending on care plan residents are repositioned or placed with proper support at least every hour. Interviews with four (4) families or responsible parties of residents in care revealed that none expressed any immediate or potential concerns about staffing or response times at this time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Due to lack of staff, residents are developing pressure injuries” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.