complaint·October 5, 2023

Allegation: “Facility staff did not properly assist resident with transfers, resulting in resident falling:” It was alleged that during the overnight shift, Resident #1 (R1) who requires assistance with transfers, was not assisted properly and R1 fell as a result. Review of R1’s resident assessment dated 08/27/2021 revealed that R1 requires one-person physical assistance with transfers and resident has not fallen within the past year. Interview revealed that Monday through Friday during daytime hours, R1 has a private caregiver assisting them with all transfers and all ADL needs during that time. Facility staff provide assistance to R1 Monday through Friday at night only, as well as all day Saturday and Sunday. Interview with R1’s family member revealed that although a one-person transfer is sufficient, facility care staff are not adequately trained, and therefore a 2-person assist with transfers is needed often. While R1’s family member did indicate a 2-person transfer is more appropriate, Resident Assessment indicating R1 requires a 1-person transfer was reviewed and signed for by R1’s family member on 08/27/2021. Interview with staff revealed that they are trained annually on assisting residents with transfers. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “facility staff did not properly assist resident with transfers, resulting in resident falling” is deemed UNSUBSTANTIATED at this time. Allegation: “Facility is understaffed:” It was alleged that during the evening, overnight and weekend shifts, the facility is understaffed. During the initial visit, LPA arrived at 6:19PM to observe evening staffing. When LPA arrived, there were 2 care staff and one medication technician present in Assisted Living, as well as one care staff and one medication technician in Memory Care. Staff interviewed indicated that medication technicians are trained and assist in meeting resident care needs and that there were 2 Memory Care caregivers present, but one was on their assigned break time when LPA arrived. Interview revealed that although the facility was experiencing some staffing concerns, the facility is utilizing agency staff to cover vacant shifts. Additionally, the facility is hosting job fairs as needed to recruit new staff. Staff interviewed did state that they are short staffed “all the time,” they also indicated that staff work double shifts and stay late to cover the vacant shifts. Staff schedule reviewed appeared to be adequate. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “facility is understaffed” is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C Allegation: “Licensee failed to provide necessary hygiene items for resident(s):” It was alleged that R1 had run out of toilet paper and when R1 asked for a replacement roll, that facility staff indicated the facility is no longer providing needed hygiene items for residents. LPA interviewed residents and staff and reviewed the facility’s policy related to hygiene items. Interview revealed that housekeeping staff replace the roll during their regular cleaning services. Care staff interviewed were unsure whether it is the facility’s policy to provide items such as toilet paper to the residents, but all staff interviewed indicated they do provide items when residents request them. Residents interviewed indicated that normally residents purchase their own toilet paper or their families provide their preferred items, but when they ask for hygiene items, facility staff do provide them timely. Based on interview and policy review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation; therefore, the allegation that “licensee failed to provide necessary hygiene items for resident(s)” is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of the report was provided.