complaint·December 28, 2021

An initial visit was done to facility on 12/15/21 to initiate investigation, during that visit at approximately 11:30 AM, LPA toured the facility along with Staff# (S1) and observed a total of 1 caregiver in memory unit for 12 residents and 1 caregiver in assisted living for a total of 21 residents, with 1 medical technician to share for both memory and assisted living units. Through interviews with staff it was communicated to LPA that normally caregiver coverage for each unit should reflect, 2 caregivers in each unit and 1 one medical technician to be shared by both units for support during the day hours, and during the overnight hours 1 caregiver in each unit and 1 shared medical technician both units. Although LPA was informed that when staff shortages and gaps occur administrative staff provide support and coverage, per staff and residents interviews this adjustment in not enough to meet the needs of residents. Furthermore, a second follow up visit was conducted on 12/28/21 in which LPA toured the facility grounds approximately 12:30 PM along with S1, and identify facility to yet again have only 1 caregiver in memory unit for 12 residents and 1 caregiver in assisted living for a total of 22 residents, with 1 medical technician to be share for both memory and assisted living units. Furthermore, review of resident records and LPA’s observations identify resident #1(R1) in room # 101, to need a Hoyer lift to help with incontinence care, bathing, and getting out a bed, a task that requires at least 2 caregivers, per staff interviews. Based on the review of staff schedules, interviews, and the needs of R1, facility lacks sufficient staff to meet the needs of residents in care, as such allegation of Facility lacks sufficient staff to meet the needs of the residents in care is being SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where this report, LIC 9099 D, and appeal rights were discussed with and provided to Associate Executive Director, Eloiza Castellanos During a visit conducted on 12/28/21 LPA toured the facility grounds approximately 12:30 PM along with S1, and conducted random interviews in rooms # 117, # 100, # 113,# 205, and room # 202, interviewing residents. Based on collected interviews, 5 out of 5 residents reported to be content with wait time, when receiving assistance from staff. Additionally, review of call light and pendant records shows a pattern of appropriate response to resident’s call. As such the allegation of, Residents are made to wait an excessive amount of time to receive assistance from staff, is being UNSUBSTANTIATED at this time, meaning that although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was done with Associate Executive Director, Eloiza Castellanos were a copy of this report was reviewed and provided.