Complaint·August 30, 2023

Allegation: Insufficient staffing to meet residents' needs. – Unsubstantiated. According to complainant, a resident had used their call button to ask for assistance but none of the staff were present on 04/30/2023. The same day complainant was told that between 2pm-6pm the facility would not have any staff members to assist the residents. The residents must wait until the new shift starts at 6pm. On 07/07/2020, the Department approved staffing ratio reduction waiver for Meadow Oaks of Roseville. A waiver for a reduction in the staffing ratio is granted due to the current reduced census of twenty-six residents. Per Stipulation and Order dated July 08, 2020 “… In the event of a substantial reduction in the census, respondents may request a reduction in minimum staffing ratios from licensing. In the event of a substantial increase in the census, licensing may increase minimum staffing ratios…” Terms and conditions of staffing ration reduction waiver: (2) qualified direct care employees during the morning shift, (2) qualified direct care employees during the evening shift, (1) qualified direct care employees during the overnight shift, and (1) qualified direct care employees (floater) available as needed. Per Meadow Oaks of Roseville’s policy on alert call system, this Community is equipped with a resident alert call system. Community staff will respond to resident alert call system activation. For the purpose of this policy, the term emergency is defined as “a potentially dangerous situation that calls for immediate action. “It is the policy of this Community that all resident alert call systems are periodically inspected to ensure they are operating correctly in the event that a resident needs to obtain assistance. Resident alert call systems are for emergency use only. Notwithstanding environmental emergencies such as fire or flood, resident alert call system use is intended for medical emergencies. Medical emergency examples include, but are not limited to, the resident has fallen; the resident is experiencing dizziness or shortness of breath; the resident is experiencing chest pain; and/or the resident has a high fever. When a resident alert call system is activated, a staff member will respond. Staff may not be able to respond immediately to resident alert call system activation. Non-emergency requests or needs should be directed to the Concierge. Examples include, but are not limited to, maintenance and housekeeping issues, bookkeeping and transportation questions. The Department requested and reviewed facility’s staff schedules from January through May of 2023. According to the April 2023 staff schedule, there are three (3) shifts, AM shift (6am-2pm), PM shift (2-10pm), and NOC shift (10pm-6am). On 04/30/2023, there were 1 Med Tech and 2 caregivers working the AM and PM in the memory care and assisted living unit. The Department also requested and reviewed six (6) residents’ pendant logs. Five (5) out of six (6) residents used their pendants and the response time was less than 20 minutes. On 4/30/2023, R2 used the pendant thirteen times. Two events show the response time was 54 minutes and 50 minutes. Interview statement received from R2 indicated, "it takes a while for staff to respond to R2's call." R2 explained S4 had recently assisted R2. S2 gave R2 the wrong painting R2 was working on and used the call pendant for S2 to come back and give R2 the right painting. The Department interviewed a total of six (6) facility staff and four (4) residents. Interview statement received from staff (S1) indicated that facility staff would sometimes call out; however, the facility always finds someone to cover shifts if needed. Interview statement received from S2 indicated, staff are picking up double shifts due to call outs and facility not hiring more staff. Interview statement received from S3 indicated that the facility is not experiencing any staffing shortages and if the facility needs staff to cover shifts, they will arrange it by calling the next shift to come in early. S3 stated if staff weren’t calling out staffing is adequate. Interview statements received from S4 and S5 denied staffing shortages at the facility. Interviews statement received from all 5 staff indicated residents’ needs are being met. Interviews gathered from facility staff indicated response time when resident uses the button for assistance is “as soon as possible” or about 5-10 minutes depending on the circumstances. Interviews from R1, R3 and R4 indicated that their needs are being met. Interview statement received from R1 indicated R1 has used the call pendant twice and the response time is reasonable. Interview statement received from R3 indicated, R3 uses the call pendant for assistance and the response time depends on what time of day R3 uses the call pendant. In the morning it’s very busy and the longest R3 had to wait for staff to assist R3 is 20 minutes. Allegation: Staff verbally abusive towards residents. - Unsubstantiated. According to complainant, two staff members (S4 & S6) are verbally abusive towards the residents. The Department interviewed a total of – facility staff and 4 residents in care. Interview statement received from 4 residents indicated that they have not experienced or witnessed any staff being verbally abusive towards the residents. The Department received an interview statement from S4 and S6. S4 and S6 denied being verbally abusive towards the residents at the facility. Based on the Department’s investigation as stated above, the preponderance of evidence standards has not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED . A finding that a complaint allegation 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.