complaint·December 29, 2022

Regarding Allegation: Insufficient staffing to meet the resident's needs. It is Alleged that that the facility only has four caregivers and that the owners themselves will work 24-hour shifts to cover. And because of this, the quality of care of the residents has slipped. It is alleged that on a regular basis, caregivers would arrive for their shifts (after the owners have worked a 24-hour shifts) to find the residents briefs/diapers to be soiled and it is alleged that two of the residents have developed pressure injuries due to sitting in soiled diapers for too long. It is alleged that there are times when a resident calls for assistance but that it can take up to 30 minutes for a caregiver to respond to the alarm. The investigation reveals that in 2020 facility had 10 total staff, that included 7 caregivers and the LIC 500, time sheets, and schedule showed that shifts had coverage 24 hours a day, 7 days a week. LPA Interviewed current staff and 3/3 denied the allegations. 9/9 current residents could not collaborate the allegations. LPA Interviewed staff that was present during 2020 and no longer employed at facility. 3 of 4 former staff interviewed collaborated the allegations as did 1 of 2 witness. No documented evidence was discovered regarding the allegation. Therefore, the allegation is unsubstantiated Regarding Allegation: Residents sustained pressure injuries while in care. It is alleged that residents sustained pressure sores while in care. LPA interviewed current residents and 9/9 did not collaborate the allegations and none had a pressure sore at the time of visit. 3/3 current staff denied the allegation. LPA interviewed former staff. 4/4 staff and 1/2 witness collaborated the allegation. Staff and one witness were able to identify former residents: FR10, FR15 and FR22 who were alleged to have developed pressure sores while in care. Review of the former resident’s FR22 file and documentation revealed that FR22 did not have pressure ulcer at the time of allegation and was under hospice care. Review of FR10 documentation revealed that FR10 arrived at facility under hospice care and with stage 4 pressure sore. Review of FR15 hospice records show that resident was admitted to hospice on 01/07/2019 and FR15 developed skin tear and wound while under hospice care. No documented evidence was discovered regarding the allegation. Therefore, the allegation is unsubstantiated Regarding Allegation: Staff are unable to manage residents' incontinence needs. It is alleged that resident’s incontinence needs were not taken care of and may have developed pressure injuries due to sitting in soiled diapers for too long. 3/3 current staff denied the allegations. 9/9 current residents could not collaborate the allegations. 1 of 2 witness did not collaborate the allegations. 4/4 former staff collaborated the allegations, however review of documentation revealed that no residents developed pressure sore due to incontinent needs not being taken care of. Only 2 resident’s that were present during 2020 are still at facility. Former residents are all presumed to have passed away. No documented evidence was discovered regarding the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted with Administrator David Kim and copy of report provided.