Complaint Investigation Report

Staffing for the month of Dec. 2025: 5- AM shifts with 2 caregivers/ 1 med tech; 5- days with 3 caregivers / 1 med tech AM; 21- days with 4 or> caregivers/ 1 med tech AM; 1- day with 3 caregivers / med tech PM; 30- days with 4 or> caregivers/ 1 med tech PM; 12- days with 2 caregivers ON; and 19 days with 3 or> caregivers ON.

Staff interviews found that staff who worked during Nov. and Dec. 2025 experienced a number of staff leaving and new staff being hired.

Staff stated that given the duties and acuity of residents in memory care such as 2 person assists, incontinent care, bathing, dressing, monitor wanderers, fall prevention plans, assist with eating , laundry, serving/ bus tables, cueing, transfer assists and unexpected occurrences, if there are too few staff, they were unable to provide care as outlined in individual plans. While staff responses varied regarding the ideal number of staff, they uniformly stated that 3 experienced staff on AM/PM made it likely that there could generally provide care as outlined in care plans with minimal occurrences of delays in care and that AM/PM shifts with only 2 caregivers made it impossible to attend to resident needs timely.

LPA reviewed incident reports submitted by the program and conducted records review of seven residents for whom there had been reported incidents. Summary of the review:

R1- dementia diagnosis, food restrictions, incontinence, wandering/ exit seeking, confusion and aggressive episodes. RO records found incident for 11/26/25.

R2- dementia diagnosis, incontinence, transfer assistance and ADL assistance.