complaint·December 23, 2024

Continued LIC9099 The activity staff assists residents during mealtimes. If one care staff needs to go on break or does not show up, there is only one caregiver available to assist residents with ADLs. Sometimes, the Med Techs assist residents with ADLs, if available. A review of the facility’s staff schedule for May 2024 shows that on May 12, 2024, only S4 worked in the morning shift. S4 confirmed with LPAs the information. When asked by LPAs how S4 managed to provide ADLs to all the residents, S4 states that it was impossible to provide all ADLs to all the residents. S4 states no residents were provided with showers and housekeeping. S4 added that although the Activity Director assisted during mealtimes and watched residents in the common areas, it was only S4 who provided care to all the residents in the unit. On 5/22/2024 when Resident 1 (R1) had a bowel accident, S4 was on break and one caregiver was with another resident. R1’s daughter requested assistance in cleaning up R1. There was no staff available to assist R1. R1’s daughter ended up giving R1 a shower to get cleaned. Staff interviewed state that there is one resident who needs 2-person assist (due to weight), 3 residents who wander and need constant redirection, 4 residents need two persons assist with showers/changing (due to behavior), 1 resident needs to be fed and 4 residents on hospice. Based on interviews and record reviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Health and Safety Code 1569.269(a)(6) is being cited on the attached LIC 9099D. Exit interview was conducted with Lydia Hertzler and Appeal Rights was provided.