Complaint Investigation Report

Allegation: Facility does not have sufficient staff in the memory care unit.

Based on LPA Kim’s observations conducted on February 13, 2025, there were twenty-two memory care residents present and four staff providing direct care. LPA observed residents’ needs were met during the visit.

Based on interviews conducted, seven out of seven residents and two out of four staff denied the allegation. The remaining two out of four staff confirmed that the facility does not have sufficient staff in the memory care unit. One staff explained each shift is sufficient to meet the care and needs for all the memory care residents. There are four caregivers with one Medication Technician (MT) per shift for AM and PM. There are two caregivers and one MT during the NOC Shift.

Based on records review, the facility has twenty-two memory care residents per the Facility Register and twenty-three staff providing care to resident in memory care unit per the Staff Schedule. The facility staff schedule shows morning shift is from 6:00 AM to 2:00 PM with two staff, and an additional staff is staggered from 10:00 AM to 6:00 PM with one staff. The afternoon shift is from 2:00 PM to 10:00 PM with two staff and an additional staff from 6:00 PM to 6:00 AM. Based on the schedule, there are four staff work as deemed necessary. Per review of the plan of operations there isn’t a required number of staff.

Based on information gathered, there is no sufficient evidence gathered to corroborate the above allegation.

Allegation: Facility failed to take the appropriate precautions to safeguard resident's property.

It is alleged the facility takes supplies from other residents if they run out. It is alleged that the management at the facility has instructed staff to take supplies from other residents if they run out. It is alleged that families have started to complain because they notice the supplies they purchase for their family member runs out too quickly and suspect they are being used for other residents in care.

Based on LPA’s observation, the facility stores memory care supplies are in a storage room. Each memory care resident has their own cubby with their names written on the hygiene supplies. During the visit, LPA Kim did not witness a situation where staff took supplies from one resident to be used for another resident in the memory care unit. LPA Kim examined multiple bathrooms and did not see any items marked with another person’s name nor any residents saying that those hygiene items belonged to somebody else.