complaint·November 19, 2024

Allegation: Staffing insufficient to meet the needs of residents. It is alleged, the administrator only has one (1) caregiver for 5 to 6 residents. On 1/24/24 LPA's review of resident roster revealed prior to LPA's initial visit six (6) residents had been at the facility. At time of the initial visit the facility census was five (5) because one resident had passed away. Three (3) residents were physically at the facility and two (2) were hospitalized. LPAs interview on 1/24/24 with staff #1 (S1) revealed that they had assisted up to (5) five residents with the help of S2. S1 stated they now assist three (3) residents and administrator helps. On 1/24/24 LPA attempted to interview three (3) residents, two (2) did not respond to questioning. LPAs interview with resident #2 (R2) revealed they have no issues or concerns with the assistance provided. On 1/24/24 administrator presented LPA with LIC 500 from January 2023. Administrator noted they had not updated personnel report. According to the administrator at time of visit the facility had one reliever (on-call), staff #4 (S4) and one full time staff, S1. A second reliever staff #5 (S5) was no longer able to work at the facility. Facility had lost one full time caregiver, staff #3(S3) on 12/23/23. S1 took over the schedule and according to administrator another caregiver, staff #2(S2) had stopped working a week prior to initial visit. According to administrator reliever and herself were working with S1 until she could hire a second staff. On 01/24/24 LPA attempted to contact previous staff and reliever. LPA left voicemail for return call for S3 and S5. Administrator could not provide contact information for S2. S4's telephone was disconnected. Review of five (5) out of seven (7) staff records on 01/24/24 revealed S1 and S4 did not have complete training. Review of S1 and staff #6 (S6) record on 11/19/24 revealed S1 has completed training since initial visit and S6 is missing orientation training. Review of six (6) resident records revealed they required assistance with incontinent care and toileting. All residents were non ambulatory of which one (1) resident was temporarily bedridden and four (4) had a diagnoses of dementia. Review of six (6) resident records on 1/24/24 revealed resident #2 (R2) did not have a pre appraisal or resident appraisal conducted. Based on resident records and review of LIC500, this allegation is deemed Substantiated at this time. Deficiencies cited on LIC 9099 D. Appeal Rights provided. Exit Interview conducted. Copy of report provided.