She expressed concern that staff may not be sufficient to monitor and care for residents safely in the memory care unit. LPA reviewed staffing schedules for January and February 2025 and observed a consistent staff-to-resident ratio. The schedules showed that the memory care unit maintained 5 caregivers and 1 med tech during daytime hours, with 4 caregiver and 1 med tech during the night shift. LPA also reviewed care plans for R1, R2, and R3. R1’s care plan included supervision in common areas, cueing for activities, and safety checks. The charting notes indicated that staff were recording observations multiple times per shift. Staff communication logs reflected shift-to-shift updates on resident behaviors and supervision needs. S1 (Executive Director) stated, “We make staffing decisions based on residents' care plans and adjust if anyone’s condition changes.” S2 added, “If we notice someone needs more one-on-one time, we increase support.” S3 said, “We’re always checking the common areas—it’s part of our routine.” S6 also stated, “Even if we’re passing meds, we’re constantly scanning the room".

Allegation: Staff are not properly supervising residents who may be a fall risk- Unsubstantiated

W1 reported that R1 experienced a fall during her stay. She expressed concern that residents at risk of falling were not being supervised appropriately. Charting notes reviewed by LPA identified R1 as a fall risk during nighttime hours while in her room. The care plan instructed staff to provide cueing, assist with transfers, and perform safety checks. Charting notes confirmed that staff conducted regular checks and documented her mobility daily. An incident report dated 01/30/25 detailed a fall in the common area, marked as "un-witnessed," and included follow-up actions such as vital signs monitoring and notification to the responsible party.

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Allegation: Staff are not properly notifying resident responsible parties of incidents in a timely manner - Unsubstantiated

W1 stated that after R1’s fall, she was not immediately informed and only learned of the incident after making her own inquiries. In the letter, she expressed frustration about not receiving prompt updates from the facility. LPA reviewed the incident reports related to R1’s fall and confirmed it included a notation of a phone call made to W1 the same day the fall happened. The facility’s internal policy requires responsible parties to be notified immediately of any significant incident. Communication logs and R1’s chart included an entry confirming that S2 spoke with W1 and provided an update on R1’s condition. S2 stated, “We make every effort to notify families within the hour. In R1’s case, Med Tech made the call that evening.” S1 added, “We train staff to report incidents immediately to management so we can handle notifications without delay.” S4 also stated, “If something happens, we write it up, radio the lead, and let them handle the family call—it’s taken seriously.”

Allegation:Staff are not providing residents with clean linen - Unsubstantiated

According to W1, she discovered R1’s bed with no sheets during her second week at the facility. She reported that R1 was lying on a bare mattress and was concerned that linens were not being changed or replaced as needed.

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LPA inspected rooms during the visit, including R1’s former room, and found clean linens present. LPA reviewed linen logs and supply inventories, which showed that clean bedding was distributed weekly and as needed. R1’s care plan indicated that staff were to provide linen changes at least three times per week and immediately if soiled. Charting notes included entries indicating linen changes for R1 on 01/18, 01/22, and 01/29. S2 stated, “If a bed is found without sheets, that’s usually because the linens were removed for cleaning and staff hadn’t finished remaking it yet.” S3 said, “Sometimes we strip the bed, step out to grab clean sheets, and come back—but we don’t leave it for long.” S5 added, “I always change sheets if they’re dirty, and we have a full linen closet on each floor.” LPA toured R1, R2 and R3’s room during the visit and observed clean linens.

Allegation: Staff are not assisting residents with meeting their bathing needs - Unsubstantiated

W1 stated that R1 did not receive any baths during her stay at the facility. She stated that R1's hygiene appeared poor and her hair remained unwashed, which raised serious concerns. LPA reviewed R1’s Care Plan, which indicated she was to be assisted with bathing twice weekly and as needed. The bathing schedule showed that R1 was assigned to bathe on Tuesdays and Fridays, with logs marking bathing assistance on 01/17, 01/21, and 01/28.There were no refusals noted in the logs. S3 stated that if there is a refusal, it is noted in the charting notes. S2 explained, “We follow the care plan, and if a resident refuses a bath, we document it and try again later.” S4 added, “we also log refusals on shower skin sheet. A sample of the log was provided to LPA. S6 said, “R1 didn’t resist bathing. We assisted her per schedule, and she was always cooperative.”

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Exit interview conducted, a copy of this report provided.