Complaint Investigation Report

Regarding the allegation: Facility has inadequate staffing to meet resident's needs.

It was alleged that the facility is understaffed in the areas of the front entrance, activities and housekeeping. The complainant reports that the facility does not have a receptionist at the desk twenty-four hours a day, which is a safety concern. However, regulatory standards do not require this facility to have a receptionist on duty twenty-four hours a day. A review of the resident agreement, which is provided to all residents upon admission to the facility, it indicates ‘For your added security, the front doors are locked at sundown and will reopen at dawn.’ Staff indicated that there isn’t a receptionist in the facility after 8:00 p.m. and the protocol for residents entering after 8:00 p.m. is to either call the main number 10-15 minutes prior to re-entry, or to press the alert button outside of the facility to alert staff of their arrival to the facility. It was communicated that staff on duty should respond to the alert buttons and/or the calls to open the front door quickly.

Out of the eleven (11) resident interviews, less than a majority of the residents indicated that they had experienced wait-times upwards to twenty-five (25) minutes when they have requested entry into the facility after 8:00 p.m. However, those residents had not called prior to arriving to the facility as preferred per protocol. The majority of residents indicated that they had received a prompt response when requesting entry into the facility after 8:00 p.m. Staff interviews revealed that at times, they are unable to respond to the front door timely due to the claim that they are assisting other residents, but staff indicated that they did carry a mobile phone and would be responsive if they were aware of a resident arrival. The LPA reviewed data from January 2023 and noted that on two occasions on 01/07/2023 and 1/11/2023, the response time for responding to the alert was between 86-93 minutes. However, it is unknown if this was an anomaly. Two occasions displayed on 1/21/2023 and 1/22/2023 in the evening was approximately 13.5 minutes, whereas there were various other times that ranged from 0-7 minutes in response time.

Regarding activities, staff interviews confirmed that the facility does not have an Activities Director. However, there are several assistants whom provide activity services and residents confirmed that the facility continues to host daily activities throughout the week. However, due to insufficient staffing in the activities department, the facility has temporarily limited community outings and has focused transportation needs to serving residents that require transportation to doctor’s appointments and grocery shopping.