Complaint·August 12, 2021

The allegations of staff are not providing adequate care and supervision to residents, facility has insufficient staffing and not providing adequate food service are interrelated in this instance and though all three are substantiated allegations they warrant only one (1) citation. Six (6) of six (6) staff interviewed acknowledged that the facility has been experiencing staff shortages for the past several months which requires the use of overtime by regular staff and use of temporary staff from an area agency. The facility continues to recruit and hire additional staff throughout this period. Three (3) of seven (7) residents expressed having experienced wait times in excess of one hour in response to the use of their pendant. R1, as reflected in the facility’s Device Activity Report, 6/22/21-7/22/21, shows 42 instances of call response times for a resident with a known heart condition. Three (3) staff reported that residents who depend on staff for activities of daily living have experienced delays or lack of assistance at times for escorts, incontinence care, transfers or dressing on those days when scheduled staff did not work. The Interim Executive Director was advised to obtain and augment as needed staff training records for “agency staff” to ensure training requirements and that staff are competent for the assistance provided to residents. Interviews with facility management found that in addition to shortages experienced for care staff, the facility has also undergone shortages of food service and serving employees. Four of seven residents reported long wait times for meals, meals, at times, arriving cold, meals not being what was requested and R1 experienced one day where they reportedly did not receive two meals. See continuation pages. The facility has instituted buffet service to reduce the number of servers needed and instituted Covid-19 mitigation compliant seatings to reduce the number of meals to be served to resident rooms. The facility also continues to rigorously attempt to recruit new staff. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights provided. The allegation that a resident sustained a death while in care is true in that residents at the facility have passed away. The allegation, however, did not specify a specific resident nor a time period. The investigation was therefore unable to find sufficient evidence. The allegation that residents are not being reappraised as necessary was vague. The example provided was related to residents safely managing motorized scooters. Residents who’s abilities are in question will be reassessed. The investigation was therefore unable to find sufficient evidence. The allegation of staff are yelling at residents while in care. Was specific to one employee who is no longer employed. Many staff who worked at that time are also unavailable. Residents and staff who have been at the facility during the time in question had not witnessed such behavior or heard of such behavior. The allegation of facility has inadequate record keeping was also vague in specifics or records or timelines. Records reviewed did not find them to be inadequate. The investigation was therefore unable to find sufficient evidence. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and report provided. Facility inspections and interviews found the facility to be clean and well maintained. LPAs observed some equipment in the kitchen which is inoperable (the gas oven), yet alternative equipment as available and operational for safe and sanitary food preparation and storage. This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Exit interview with Administrator.