complaint·December 6, 2023

Residents sustained falls due to lack of supervision - UNSUBSTANTIATED It was reported that residents are falling because there is only one staff providing care and supervision in the memory care unit. LPA reviewed records of falls that were reported for the months of September through November 2023. One memory care resident fell on 09/18/23, was transported to hospital for assessment. There were no falls reported for the month of October 2023 and thus far none for the month of November 2023 in the memory care unit. LPA reviewed memory care staffing schedules for the months of September and October 2023. The facility has four shifts in the memory care unit. All shifts had one Med Tech and one to two PCA’s. In addition, the facility has recently increased their staffing in the memory care unit. During the month of September 2023 PCA’s called out or did not show up for their shifts on the following days during the 6:00 am – 2:00 pm shift exclusively: five days no show. 9two days PCA – Personal. One day PCA – Sick. On 9/17 two PCAs did not show up for their shifts which resulted in one PCA working back-to-back shifts to cover. 3 of 5 staff stated 2 residents have fallen, one fall resulted in a contusion. 1 of 5 staff stated that one resident fell from time to time but was not injured. 1 of 5 staff stated they did not know if there had been any falls. Expressions Director stated I have enough staff when they don’t call in with me back here also. Executive Director stated there are two care staff, the med tech and the director on duty to provide care. It was determined that the facility has not had an increase in falls due to insufficient staffing and lack of supervision. This allegation is unsubstantiated. Continued LIC9099-C Staff are not meeting resident’s hygiene needs. - UNSUBSTANTIATED It was reported that care is not being provided because there is only one staff providing care and supervision in the memory care unit. LPA reviewed memory care staffing schedules for the months of September and October 2023. The facility has four shifts in the memory care unit. All shifts had one Med Tech and one to two PCA’s. In addition, the facility has recently increased their staffing in the memory care unit. When staff were asked if care was being provided timely for the residents 1 of 5 staff stated they tried but when there is only one staff on the floor it’s hard. 1 of 5 staff stated No because there are not 2 PCAs in the memory care unit 24/7. 1 of 5 staff stated It is hard to get to all of the residents because they are dealing with other residents but thought that most are getting care in a timely manner. 1 of 5 staff stated now that there are 2 PCAs in the memory care unit care is going a lot smoother. Expressions Director stated brushing teeth, brushing hair and applying deodorant should be a daily task. Staff assist them. They are logged in our PCC (Point-Click-Care) as a task under hygiene and grooming. Executive Director stated We try to encourage the residents every day, it depends on their mood, every resident is different. Sometimes some of them don’t want to have it done in but we encourage the best we can. All ADLS are encouraged and done in the manner the residents accept. It was determined that staffing is sufficient to ensure that resident hygiene needs are being met. 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. An exit interview was conducted. A copy of the report was provided to Executive Director Sonya Gonzales.