Complaint Investigation Report

She expressed concern that staff may not be sufficient to monitor and care for residents safely in the memory care unit. LPA reviewed staffing schedules for January and February 2025 and observed a consistent staff-to-resident ratio. The schedules showed that the memory care unit maintained 5 caregivers and 1 med tech during daytime hours, with 4 caregiver and 1 med tech during the night shift. LPA also reviewed care plans for R1, R2, and R3. R1’s care plan included supervision in common areas, cueing for activities, and safety checks. The charting notes indicated that staff were recording observations multiple times per shift. Staff communication logs reflected shift-to-shift updates on resident behaviors and supervision needs. S1 (Executive Director) stated, “We make staffing decisions based on residents' care plans and adjust if anyone’s condition changes.” S2 added, “If we notice someone needs more one-on-one time, we increase support.” S3 said, “We’re always checking the common areas—it’s part of our routine.” S6 also stated, “Even if we’re passing meds, we’re constantly scanning the room".

Allegation: Staff are not properly supervising residents who may be a fall risk - Unsubstantiated

W1 reported that R1 experienced a fall during her stay. She expressed concern that residents at risk of falling were not being supervised appropriately. Charting notes reviewed by LPA identified R1 as a fall risk during nighttime hours while in her room. The care plan instructed staff to provide cueing, assist with transfers, and perform safety checks. Charting notes confirmed that staff conducted regular checks and documented her mobility daily. An incident report dated 01/30/25 detailed a fall in the common area, marked as "un-witnessed," and included follow-up actions such as vital signs monitoring and notification to the responsible party.