complaint·December 19, 2023

Page 2 Not enough staff to meet the needs of the residents - UNSUBSTANTIATED It was reported that there are not enough staff to care for the residents. Document review of staffing schedules revealed that on the assisted living side of the facility the facility is staffing 2 PCA’s with one Med Tech working both the assisted Living and Expressions sides of the facility. In December 2023 the facility increased their staffing to 2 PCA’s and 1 Med Tech who works exclusively in the assisted living side of the building. Resident interviews revealed that some residents think there are not enough staff and some think there are enough staff. During staff interviews it was learned that staff do call out, and when staff call out administration places telephone calls, sends text and group chat with all employees and requests coverage. Executive Director stated when staff call out they replace them with other staff. It was determined that due to low resident census on the assisted living side of the facility, the facility was staffing 2 PCA’s with 1 Med Tech working both the assisted living and memory care portions of the facility. The facility has recently increased staffing so assisted living has their own Med Tech separate from memory care. This allegation is unsubstantiated. Page 3 Resident rooms are not being cleaned regularly - UNSUBSTANTIATED It was reported that the facility is not cleaning rooms regularly and residents had to pick up and clean their room as it is not being done. It was also reported that a resident had a BM accident on their floor that was not cleaned for over 24 hours. During staff interviews it was learned that housekeeping staff clean the resident rooms. If care staff notice that a room is messy they will clean up the room but do not deep clean. Staff who were interviewed stated they did not know about the BM on the floor. Executive Director stated that housekeeping staff clean each room once a week (light housekeeping) per the contract. If care staff sees an accident they clean it up. When the resident had the accident staff cleaned it up, but at 6:30 PM the same day the resident notified staff that it needed to be cleaned more. As soon as it was identified the area was cleaned again. It was determined that housekeeping staff regularly clean the resident rooms as scheduled, care staff will clean up accidents when they see them and the specific incident was attended to in a reasonable amount of time. This allegation is unsubstantiated. Continued on LIC9099-C Page 4 Staff do not properly administer resident medication - UNSUBSTANTIATED It was reported that staffing issues have resulted in residents not getting their medication on time. Resident interviews revealed that residents don’t normally have to wait to receive their medication but one day the med tech wasn’t at work so they had to wait. Residents stated they have not had to wait longer than usual for their medications. Staff interviews revealed that one day there was only one med tech and a few residents were upset. If there is only one med tech working both floors some residents have had to wait about 1 hour for their medication. Executive Director stated they are dispensing medications within the accepted time frame of the hour before or after scheduled dosage. Medication dispensing is tracked using the point click care system which alerts staff if a resident is waiting too long for their medication. It was determined that occasionally residents may have to wait a little longer for medications but they do receive their medications within the required window of time. Additionally, the facility has recently increased staffing so assisted living has their own Med Tech separate from memory care. This allegation is unsubstantiated. Continued on LIC9099-C Page 5 Call lights are not being answered timely - UNSUBSTANTIATED It was reported that there are very long wait times when call buttons are pushed LPA review of provided call light audit data for September 2023 revealed that the response time was under 2 minutes for the PM shift, under 1 minute for the NOC shift, and under 3 minutes for the AM shift. One resident stated they had to wait 30 minutes for their call light to be answered, one resident stated that when they press their call button it is answered fast. Staff interviews revealed that it takes about 15 to 20 minutes for call lights to be answered, The facility recently got a pager system, the med tech and PCA carry the pagers and since then the call lights are being answered a lot faster. Executive Director stated The average wait is 3-5 minutes for a call light to be answered. The facility runs a random pull chord time weekly audit but can’t pull individual room and date data in the audit. It was determined that call lights are being answered in an acceptable amount of time. 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.