Complaint Investigation Report

The same observations were made during subsequent visits conducted on 8/23/2023, 8/31/2023 and 9/13/2023. Facility management indicated that they were not aware that kitchen staff continued not to be in compliance. During staff interviews, it was indicated that the facility inventory for these items had run out. Management indicated that purchase orders had been placed and was unaware the merchandise had not arrived. On September 13, 2023, management went out to purchase enough supplies and instructed kitchen staff to immediately start using the protective equipment as required.

It was also alleged that sufficient staff were not scheduled to meet residents’ needs. Based on the review of the assignment sheets for the months of July and August 2023 it appears that for the most part, there were enough caregivers scheduled to work per shift. However, there were times when caregivers called out and it wasn't clear which caregiver provided coverage on that particular day or if coverage was provided.

During a visit conducted on 9/13/2023, 9:45 am, LPA observed that staffing during the morning shift on this day was not sufficient to meet residents' needs. It was observed that there was only one caregiver and one medication technician to meet the needs of 98 residents in Assisted Living. In addition, both the Executive Director and the Resident Services Director were not present at the facility. The Sales Director was also out and not available. There were no management staff present at the facility. During the visit, approximately at noon, the Executive Director arrived at the facility to provide coverage as a caregiver until the staffing level was back to normal during the afternoon shift which started at 2:00 p.m. The Executive Director indicated that they had unanticipated callouts and there were no available caregivers to provide the necessary coverage. The Executive Director stated she was telecommuting doing training and was available via telephone and informed of the staffing situation and came in to provide coverage. The Executive Director indicated the Resident Services Director was out on leave. During staff interviews, it was indicated that the facility was not contracted with a temporary agency for caregivers. In addition, during interviews with staff and outside sources, it was indicated that at times when caregivers call out unexpectedly or are out due to an illness there were no available caregivers in the employee roster to provide the needed coverage. Staff also indicated that caregivers would need to work double shifts due to understaffed conditions. Based on observations on 9/13/2023, the staffing level for care staff was not sufficient to meet the needs of the residents in assisted living.