complaint·April 28, 2025

(Continued from LIC9099) The three (3) residents not interviewed were sleeping, at the hospital, or did not respond to LPA's questions. On 3/11/2025 from approximately 12:20 p.m. to 12:50 p.m., LPA conducted interviews with two (2) staff present and the assistant administrator. On 3/11/2025 from 12:50 p.m. to 1:45 LPA reviewed resident and staff records and obtained copies of residents’ Physician's Reports (LIC602A) and Appraisal / Needs and Services Plan (LIC625). Allegation: Staff did not ensure facility had adequate staffing to meet resident's needs. Regarding the allegation, it was reported there is no overnight staff. To investigate the allegation LPA Rios conducted an initial visit on 3/11/2025. LPA's review of the facility's LIC500 revealed most shifts are from “7AM” to “7PM” with no overnight shift. The staff monthly schedule reveled two staff names on each day for this facility. The staff monthly schedule does not have which hours the staff member is covering. The assistant administrator admitted not verbatim that prior to three (3) weeks ago they did not have an overnight staff on schedule so relied on live-in staff to wake up and provide assistance when needed. Staff corroborated that there was no overnight staff assigned to provide care; however, staff would wake up if needed to assist residents with agitation, wandering, or incontinence needs. Staff interviews revealed that there is now one (1) awake staff member overnight to check on residents. LPA's review of facility's program under Basic Services states verbatim "Checks will be made on a regular basis, including night time. Patterns of incontinence will be discussed with physician. Night time, awake staff will be employed as necessary." Based on interviews and record review the allegation is deemed Substantiated. Deficiency cited (refer to LIC9099-D). Exit interview conducted. Copy of report provided. (Continued from LIC9099-A) The three (3) residents not interviewed were sleeping, at the hospital, or did not respond to LPA's questions. On 3/11/2025 from approximately 12:20 p.m. to 12:50 p.m., LPA conducted interviews with two (2) staff present and the assistant administrator. On 3/11/2025 from 12:50 p.m. to 1:45 LPA reviewed resident and staff records and obtained copies of residents’ Physician's Reports (LIC602A) and Appraisal / Needs and Services Plan (LIC625). Allegation: Staff left resident soiled for an extended period of time. Allegation: Staff did not respond to resident's call button in a timely manner. Regarding the allegations, it was reported that Resident #1 (R1) requested toileting assistance around 3:00 a.m. but did not receive timely attention, resulting in being left in soiled undergarments. LPA's interview with the assistant administrator revealed that a complaint had been received by the facility a few weeks ago from a resident's family member about how staff treated the resident. According to the assistant administrator, Staff #1 (S1) and Staff #2 (S2) were let go as a precaution based on the statements made by the family. LPA's review of residents’ LIC602 and LIC625 revealed resident have bowel and bladder impairment. LPAs interview with staff on 3/11/2025, corroborates all current residents require incontinence care. The assistant administrator admitted not verbatim that prior to three (3) weeks ago they did not have an overnight staff on schedule so relied on live-in staff to wake up and provide assistance when needed. Staff corroborated that there was no overnight staff assigned to provide care; however, staff would wake up if needed to assist residents with agitation, wandering, or incontinence needs. Staff interviews revealed that there is now one (1) awake staff member overnight to check on residents. LPAs interview with staff on 3/11/2025 deny witnessing residents in soiled diapers from the previous shift or not attending to residents timely except for when they were assisting another resident in which case they would excuse themselves to check on the resident that was calling for assistance. LPA's interview with three (3) current residents revealed that wait times do vary not specific to the time of day but that they have no concerns about the wait time. Based on interviews and record review the allegations are unsubstantiated. Exit Interview. Copy of report provided.