Complaint Investigation Report

S1 is doing all the resident care, cooking and screening of visitors and is left to also assist with this visit with LPA Goldenberg drawing them away from resident care. Review of resident records revealed the following: Four (4) of six (6) residents require moderate care in all activities of daily living. Three (3) of six (6) residents have a diagnosis of Dementia and require supervision. One (1) of six (6) residents requires assistance with ambulation.

S1 admits to being tired and without assistance for the last 24 hours, but also states has been on duty even longer providing care for residents around the clock. It is clear that there is not enough staff to provide a safe environment in which staff are able to meet the residents needs according to their assistance level and admission agreement.

We have substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D.