complaint·May 28, 2021

Regarding allegation: Facility staff are not providing timely care for resident's hygiene needs. It is alleged resident has a diaper rash, and has ulcers due to the diaper rash and staff not applying diaper rash cream and/or attending to the residents timely. During interviews with 2 out of 10 residents stated to receive assistance with their daily living timely, 5 out of 10 stated to not required assistance with daily living, and 3 out of 10 residents were not able to respond to interview due to cognitive or verbal skills. Interviews with 4 out of 8 staff stated that there is not sufficient caregivers at the facility, however the caregivers prioritize care for the residents incontinence care needs and meals. 2 out of 8 staff are not familiar with residents care and 2 out of 8 staff stated staff have not reported to not be able to meet residents needs and caregivers are provided assistance to provide care to residents. During document review zero (0) out of 10 residents review are under hospice care care and/or have any notes in their files regarding ulcers or diaper rash. Based on interviews and resident's documents reviewed the preponderance of evidence standard has been met, therefore the above allegation is UNSUBSTANTIATED. Exit interview was conducted with Lori Lackey assistant administrator and a copy of this report was provided. The investigation revealed the following: Regarding allegations: Staff did not ensure facility was free from pests. It is alleged facility has cockroaches in the rooms, bathrooms and the kitchen and the facility has bed begs. During the tour of the facility LPAs observed kitchen and common areas were free of pest and a cockroach in room #204's shower. During interviews with 6 out 10 residents stated not to have observed cockroaches in their rooms or the facility. 1 out of 10 residents stated that facility does have a problem with keeping facility free of cockroaches and 3 out of 10 residents were not able to answer interview questions due to cognitive or verbal skills. Interviews with 8 out of 8 staff stated to have observed cockroaches in the kitchen, and resident's rooms, and facility is under pest control treatment once a month and 4 out of the 8 staff stated facility was treated for bed bugs. Documents reviewed for pest control invoices for September, October, November, December 2020 noted the kitchen was service for cockroach treatment and invoices for March and April 2021 showed rooms #230,249,251,255,234,232,228,222,211, staff break rooms were treated for cockroaches and staff stated janitor applies heater daily in random rooms for bed bugs. Based on observation, interviews, and document review conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found SUBSTANTIATED. Regarding allegation: Residents are not getting meals on time due to lack of staff. It is alleged at night there are 4 staff to 97 residents and residents are not getting meals on time. During interviews with 7 out of 10 residents stated to receive their meals timely and sufficient amount of food. 1 out of the 7 residents stated that there is not sufficient staff at the facility, and 3 out of 10 residents interviews were unable to provide answers due to cognitive or verbal skills. Interviews with 4 out of 8 staff interviewed stated there is not sufficient staff at the facility. Staff stated to be assigned 16 residents on a regular basis and up to 19 residents when other caregivers are out. However, staff prioritize meals and incontinence change for all residents. 2 out of 8 staff stated that there is sufficient staff at the facility and 2 out of 8 are not aware of staffing issues. Based on caregivers schedule reviewed for the week of 5/21/21 to 5/28/21 caregivers were assigned to 13-14 residents on a regular shift and 16-18 residents when other caregivers were out, which was 4 out of 8 days. It should be noted there are 6 residents under hospice, 0 residents that are bedridden, and 23 residents non-ambulatory. Based on interviews, and document review conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC9099D. Exit interview was conducted with Lori Lackey assistant administrator and a copy of the report, LIC9099D,and appeal rights was provided.