Complaint Investigation Report

Resident R1’s Care Plan prepared by the hospice program was also observed to state that R1 requires assistance with most daily activities. LPA reviewed facility staff time sheets for the period of 8/1/2025 through 8/30/2025. The facility has three (3) defined shifts. The AM shift is 6:00AM-2:30PM. The PM shift is 2:00PM-10:30PM. The Night (NOC/Nocturnal) shift is 10:00PM-6:30AM. During the time frame noted the AM shift was observed to typically have four (4) to five (5) staff members providing care. There were several AM shifts that were observed to have six (6) or seven (7) staff members providing care. During the time frame noted the PM shift was observed to typically have four (4) staff members providing care. The PM shift was observed to typically have three (3) to four (4) staff members providing care. The NOC shift was observed to have three (3) staff members providing care. During the time frame observed (8/1/2025-8/30/2025) there was adequate staffing levels to help R1 with their daily care needs. LPA interviewed R1’s Hospice Case Manager with Sutter’s Care at Home program. The case manager stated they think the facility is meeting the care needs of their hospice residents and that the facility cares about the level of care they provide. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited during today's visit.

Exit interview conducted. Copy of report discussed and provided to Resident Care Coordinator Short. Signature on form confirms receipt of documents.