Facility Evaluation Report

On today's date, Licensing Program Analyst (LPA) Michael Tea conducted this case management in conjunction with the continued Complaint visit Control #: 22-AS-20251003170854. LPA Tea met with Executive Director (ED) John Goodwin and discussed the purpose of today's case management visit.

During the course of the complaint investigation, LPA Tea verified through interviews that seven out of nine interviewees reported the facility was inadequately staffed at the time of the incident. Several staff members stated they were responsible for an excessive number of residents, with some indicating they were assigned to an entire floor independently. It was further reported that during the nocturnal shift in the Memory Care unit, only one care staff member was on duty. Insufficient staffing levels were described as negatively affecting the quality of care, timeliness of assistance, and overall supervision provided to residents. The LPA’s own observations during the investigation supported these accounts, indicating that the number of staff present was insufficient to meet residents’ needs. However, it was also noted that following the incident, the facility increased staffing levels across various shifts to provide more consistent coverage throughout the day.

Based on documents reviewed and interviews conducted, no deficiencies are being cited at this time. However, the LPA provided a technical advisory regarding inadequate staffing.

An exit interview was conducted with Executive Director John Goodwin. Copies of LIC809 and LIC9102TV were provided at exit.