complaint·January 18, 2024

Regarding Allegation #1: Facility personnel are always not sufficient in numbers to prevent residents from falling. This complaint alleged that facility personnel are not sufficient to prevent residents from falling. LPA Calderon conducted an interview with A1. A1 expressed that the facility is not understaffed, and residents do not fall due to lack of staffing. A1 said that the facility has floaters that work on each floor as needed. A1 expressed that staff need to do is call for assistance and a nurse, LVN or floater will be there to help with residents’ needs. LPA Calderon conducted an interview with S1-S8. 8 out of 8 staff expressed that the facility is understaffed, and residents fall due to health condition and staffing issues. 8 out of 8 staff state that the resident to staff ratio on average is 8 to 1 per floor. 8 out of 8 staff said that there are higher ratios on different floors and that there are 2 staff floaters that help with the care of residents. 8 out of 8 staff state that there are 2 staff med-tects in the facility to support the care staff with the needs of residents but for the most part there is only 1 staff member on any floor and falls do happen. LPA Calderon attempted to interview R1-R6. 6 out of 6 residents were unable to communicate due to impairments. Regarding Allegation #2: Facility personnel are always not sufficient in numbers to answer resident call button in a timely manner. This complaint alleged that there is not enough staff to answer residents call button. LPA Calderon conducted an interview with A1. A1 expressed that the day shift and night shift are different because most residents are sleeping on the night shift and there are less residents that push the call button. A1 expressed that there is an 8 to 1 ratio and 2 floaters and 2 med-tecks that work each day and night shift and any time a call button is pushed staff answers. A1 expressed that there are no staffing issues and there are enough staff to answer call buttons within 3 to 7 minutes. LPA Calderon conducted an interview with S1-S8. 8 out of 8 staff said that most of the time the call button is not pushed at night as residents are sleeping. 8 out of 8 staff expressed that on average the call button is pushed more often in the daytime as most residents are out of bed. 8 out of 8 staff state that there are not enough staff to answer the resident call button and on average it takes 5 to 10 minutes depending on the resident situation. LPA Calderon attempted to interview R1-R6. 6 out of 6 residents were unable to communicate due to impairments. Regarding Allegation 3: Facility personnel are always not sufficient in numbers to meet resident needs for incontinence care. This complaint alleged that there are not enough staff to meet incontinence care . LPA Calderon conducted an interview with A1. A1 expressed that not all residents in care need incontinence services. A1 expressed that most residents diaper can be changed by one staff member. A1 expressed that there are 2 staff floaters and 2 staff med-tects that work every shift. A1 expressed that if staff needs help with residents’ incontinence care staff can make a call for assistance. A1 expressed that there is no staffing issue at the facility and there are enough staff to take care of the residents with incontinence care. LPA Calderon conducted an interview with S1-S8. 8 out of 8 staff said that there are staffing issues in the facility. 8 out of 8 staff said that not all residents in the care need incontinence services. 8 out of 8 staff expressed that due to staffing issues it takes longer to care for residents with incontinence needs. LPA Calderon attempted to interview R1-R6. 6 out of 6 residents were unable to communicate due to impairments. On 07/07/2023 LPA Calderon reviewed staff training records for incontinence care (dated 5/27/2023) and log notes for March and April and May 2023 which support staff providing incontinence care to resident. Regarding Allegation #4: Facility personnel are always not sufficient in numbers to meet resident needs for showering. This complaint alleged that there are not enough staff to meet resident showering needs. LPA Calderon conducted an interview with A1. A1 expressed that staffing needs are different from the day shift to night shift and are different care needs per floor. A1 expressed that there are 2 staff floaters and 2 staff med-tects that work each shift. A1 expressed that not all residents are given a shower at the same time or on the same day and that there is always another staff member to support the floor caregiver when needed. A1 expressed that no resident goes without a shower. LPA Calderon conducted an interview with S1-S8. 8 out of 8 staff said that the staff to resident ratio changes per floor. 8 out of 8 staff expressed that giving a shower or bath to a resident is a 2-person job and most times there is only 1 staff member to give a resident a shower. 8 out of 8 staff said there are staffing issues and not enough staff to clean all residents timely. LPA Calderon attempted to interview R1-R6. 6 out of 6 residents were unable to communicate due to impairments. On 07/27/2023 LPA Calderon reviewed staff training records for showering residents (dated 05/04/2023). LPA Calderon reviewed log notes for March and April 2022 for staff giving showers to residents. Reviewed caregivers’ duty (dated 5/17/2023), and staff rounds training (dated 05/11/2023). LPA Calderon noted staff trained on how to shower resident, but limited staff have the training. Although the allegation may have happened or is valid, there is a preponderance of evidence to prove the alleged violation(s) did occur, therefore the allegation “facility personal are not sufficient in numbers at all times to prevent residents from falling” “ facility personnel are not sufficient in numbers at all times to answer resident call button in a timely manner” “facility personnel are not sufficient in numbers at all times to meet resident needs for incontinence care” “facility personnel are not sufficient in numbers at all times to meet resident needs for showering” is substantiated. California Code of Regulations, Title 22, Division 6 are cited on the attached LIC 9099D. An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to the Administrator Kenia Padilla (A1).