Complaint Investigation Report

after midnight and during the day to provide care and supervision. It is also alleged that staff does not have enough supplies to perform their jobs and there isn’t any front desk coverage after midnight for emergency personnel entrance and for families to reach memory care residents. Record review of Fire Inspection allows for the facility to have locked doors in the memory care unit. Review of staff schedule (12/21/25 - 12/27/25) revealed one staff worked in memory care during the PM and NOC shift on 12/21/25, 12/27/25. One staff worked in memory care on 12/22/25 (2:30 PM - 11:00 PM). One staff worked in memory care on 12/23/25 - 01/02/26 (11:00 PM - 7:30 AM). Review of staff schedule (12/28/25 – 01/03/26) revealed one staff worked in memory care during the PM and NOC shift on 12/28/25 - 12/29/25, 01/03/26. One staff worked in memory care on 12/30/25 - 01/02/26 (11:00 PM - 7:30 AM). Two out of three staff interviews (S1, S3, S6) indicated there are two staff working in memory care and rounds are conducted every two hours or less. S5 and S7 indicated working with another staff member in zone one (assisted living on the first floor). S1 indicated there are eleven residents in memory care (zone three). S6 indicated most residents are sleep around 8:00pm. Five out of five staff interviews (S1, S3, S5 - S7) indicated there is enough supplies for caregivers. Five out of five staff interviews (S1, S3, S5 – S7) indicated someone works at the front desk after midnight who is able to grant access to emergency personnel and transfer phone calls from families to memory care. S8 indicated there is always a caregiver working the front desk overnight and use radios to inform of incoming phone calls. Three out of three Memory Care Emergency Contact (W3 - W4, W6) indicated care and supervision is provided to residents in memory care. Four out of four Memory Care Emergency Contact (W1, W3-W4, W6) indicated they have not tried to call the facility after 10pm.

On 01/08/26 (9:40 AM – 10:00 AM), LPA toured and observed a locked door device that requires a key scan to enter the Memory Care Unit. The area also included an aiphone that rings to the front desk. Memory Care has a phone in the common room and in the office. The phone in the common room was tested and the front desk answered. While at the front desk, LPA and staff tested memory care's radio and a caregiver responded. LPA also observed the Paging System at the front desk. Staff was able to make an announcement that went throughout the building. LPA also observed supplies for the caregivers to access them.