complaint·June 18, 2024

Page 1 Care is not being provided timely due to low staffing - SUBSTANTIATED It was reported that the facility has low staffing especially at night and weekends. Only 1 caregiver on several occasions in the assisted living side and care is significantly affected. LPA reviewed the staffing schedule for the dates of 3/29/2024 through 04/02/2024 and found that during the NOC shift on 04/01/2024 and 04/02/2024 there was one med tech on the assisted living side and 1 PCA on the memory care side of the facility. Staff stated that residents do not wait a long time for toileting assistance. Resident interviews revealed that sometimes caregivers are other places and they understand but sometimes it takes too long. It was determined on 04/01/2024 and 04/02/2024 during the NOC shift there was one med tech on the assisted living side and 1 PCA on the memory care side of the facility. This is inadequate staffing to ensure proper care and supervision of all residents. This allegation is substantiated. Continued on LIC9099-C Page 2 Residents are not receiving showers as listed in their care plan. – SUBSTANTIATED It was reported that a resident who is supposed to have 4 showers per week had to wait 6 days for a shower. LPA reviewed Resident 3’s (R3) care plan dated 04/21/2023 which states that staff will provide physical assistance with showers per the shower schedule. R3’s Physician’s Report states R1 is unable to bathe themself. According to R3’s Service Plan they require physical assistance with four showers per week. LPA reviewed R3’s Activities of Daily Living (ADL) charting for the month of March 2024. Only five days indicated that R3 had received a shower, 14 days indicated that no service was needed on those days, and on 12 days no charting was completed. On the 12 days where no charting was completed it is unknown as to whether R1 received a shower as scheduled. Staff stated that R3 gets showers on Sunday, Monday, Wednesday, and Friday. There has been one or two times that R3 wanted to wait to take their shower but then it’s too late to complete the shower because it takes 2 hours to give R3 a shower. Staff always try to get to R3 in the morning the next day. When R3 was recently discharged from the hospital they didn’t get a shower for 2 days because R3 was very weak. At the time of the interview R3 stated three or four weeks ago they had gone 6 days without showering due to low staffing. R3 stated they had not refused showers. Continued on LIC9099-C Page 3 ED stated there have been times just recently where staff try to give R3 a shower and they have refused three days in a row. Staff reported they were trying to work with R3 but R3 is refusing. LPA questioned ED regarding the ADL charting and the fact that 12 days showed no charting for showers for R1. LPA questioned how the facility charts when a resident has refused their shower. Ed stated if a shower was refused the ADL chart would be dated and in the comments it would indicate an "R" with the initial of staff and a time stamp. ED stated for this month (March 2024) and this resident, the documentation is poor and unfortunately does not show for R1’s showers. It was determined that staff are offering R3 showers and occasionally R3 does refuse showers. However, staff are not properly documenting when R1 refuses showers. According to the ADL charting there are 12 days where no charting for bathing R1 was completed. The facility needs to improve their Activities of Daily Living (ADL) charting practices using the Point-Click-Care system. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation that staff financially abused a resident is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to executive director Sonya Gonzalez.