Complaint Investigation Report

Staff informed of instances where there was one (1) caregiver responding to all Assisted Living residents, and staff informing residents that they would return but never coming back to assist them. Staff interviews showed that that staff attempted to assist residents timely, but insufficient staffing had resulted in residents waiting for long periods of time for assistance. Staff informed that families have confronted them about only one (1) staff member working the floor and there not being enough help for residents.

Outside source interviews were mixed regarding resident wait times. One outside source informed observing resident wait times between 5-10 minutes. A second outside source informed that staff did not respond for 30 minutes when their resident pushed their pendant for help. A third outside source did not have specific wait times for pendant responses, but expressed concern with how few staff have been observed assisting the residents in memory care. The third outside source informed that staff have admitted that there were not enough caregivers on each shift to meet the residents' needs.

Review of facility call button records during the timeframe of complaint revealed that between 01/19/25 11:28pm to 01/24/25 2:59pm, within less than a 5-day period, there were 55 pendant calls with wait times 20 minutes or above, with the longest recorded time being 86 minutes (18 pager announcements to staff) and one call with which there was no response by staff (21 pager announcements to staff before the announcements ceased). This record corroborates the reporting party statements as well as staff and resident interviews that residents commonly waited for extended periods for staff assistance.

Regarding the allegation, "Licensee did not ensure chemicals were properly stored", it was alleged that hazardous chemicals were accessible in a first floor storage room and on an outdoor patio. Staff members who were interviewed consistently denied observing or being aware of any chemicals that were accessible to residents. No staff members interviewed had been informed by any resident that chemicals were not properly stored.

An outside source informed that a door to a room containing chemicals on the first floor was unlocked during a visit. A second outside source denied observing any chemicals that had been improperly stored or made accessible to residents.

During unannounced facility visits on 01/24/25 and 02/21/25 LPA directly observed the first floor laundry room unlocked and unattended by staff. (Continued on LIC9099-C p. 3)