It was reported that resident needs are not met to include toileting, two-person assists, medication passed late, residents not being brought to dining room for meals due to insufficient staffing.

LPA reviewed staffing schedule for January 2026. Combining all staff on duty for the assisted living and memory care units, the AM shift had an average of 2 med techs and 3 or 4 care staff. PM shift had 2 med techs and 3 care staff. NOC shift had 1 med tech and 2 care staff. These numbers reflect any staff call outs being accounted for in the totals.

LPA interviewed six staff. 4 of 6 staff stated the facility struggles with staff calling out. 3 of 6 staff stated there are not enough staff on shift to provide timely toileting assistance or lift residents who require a two person assist. 2 of 4 staff stated if a med tech is being utilized for care giving tasks the medications are sometimes passed late. All staff stated that residents are brought to the dining room timely for meals. During interviews staff did not provide specific instances where care was not provided timely to residents as a result of insufficient staffing.

ED stated the facility schedules 1 med tech and 2 care givers for each shift and each floor, assisted living and memory care. When staff call out the facility has one staff person floating in between floors. If the facility is “staff challenged” the ED or a manager will come in to assist on the floor. ED also stated there was one day in 2026 during a PM shift that all staff called out. ED stated that they came in and covered the shift and the staff who were already working from the AM shift stayed and worked through the PM shift that day. Overtime is paid to any staff who work over their scheduled shift.

It was determined that facility generally has an acceptable staffing schedule and when staff call out management does come in and assist. In addition staff will chose to work overtime which they are compensated for. This allegation is unsubstantiated.

Continued on LIC9099-C

It was reported that the facility is working new staff by themselves without proper training.

LPA reviewed online training documentation for two new staff who had been hired in January 2026. Both staff completed online training: Total hours online training for care staff is 40, med techs completed 60 hours. LPA reviewed competency verification test results for the two staff.

5 of 6 staff stated that new staff get the required training they need.

ED stated they meet with new staff to see if they need anything else and some will say they need more training. Recently the only one staff that said anything said they wanted more training with transfers so the staff was given more training. This allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to Executive Director Irene Davis.