complaint·April 16, 2024

The facility’s Admission Agreement template from 2010 in the facility file in the Sacramento CCLD office, identifies: Level Four- Extensive Assistance . Resident requires extensive assistance for personal care, bowel and bladder management, and health care monitoring. Behavior may be unpredictable and continual orientation and cueing may be needed for all basic functioning. Housekeeping and laundry needs may be more than daily. All services in Levels One, Two and Three would be required; Level Three- Moderate assistance. Resident's needs are more intense and include moderate assistance in activities of daily living as well as constant supervision and moderate assistance for dressing and bathing. Medication administration assistance may be more complex, and health monitoring may be as often as daily (e.g., blood pressure checks). Physical assistance in preparation for and during transports outside the facility may be necessary. Physical assistance and escort to the dining room and constant cueing and assistance during mealtimes would most likely be needed. Tray services may be used frequently. Laundry and housekeeping services may be required daily. Resident may require regular assistance in bowel and bladder management. All services included in Levels One and Two would be required; and Level Two- Minimal Assistance . The DAR provided to the investigating LPA contained approximately 835 pendant calls for the week or 2/11/24-2/18/24 in Assisted Living. Of the 835 calls, LPA found that approximately 177 responses exceeded 20 minutes. Given the content of the complaint allegation, LPA then reviewed information for 2/15/24, Hall 1, and found that there were 16 call responses exceeding 19 minutes and 50 seconds. 10 of the incidents, in Hall 1 on 2/15/24, occurred on the AM shift and 6 on the PM shift. Of the residents impacted by call response delays, 4 were designated as Level Three and 1 was Level Four. Resident records indicate that the longest recorded response times, in Hall 1, on 2/15/24 were experienced by R1, who is Level 4, who had a wait time of 63:05 (min:sec) and R5, who is Level 3, had a wait time of 67:42 (min:sec). R1’s delay occurred at 10:48 AM and interviews conducted found that the delay resulted in a delay in incontinence care for R1. When interviewed by LPA, R5 was unable to recall the reason for their call on 2/15/24. However, R5’s ODL identifies R5 as using a catheter, needing stand-by assist for toileting, is a fall risk and requires frequent check. CCR 87411 Personnel Requirements – General states, in part, “Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.” LPA interviewed seven (7) residents who had recorded incidents of long (greater that 19 min 50 sec) response times. Seven of seven residents interviewed stated that while many response times are less than 15 minutes, they all have experienced response times more than 20 minutes. All seven have had staff explain delays to them as staff were providing service to another resident as the reason for the delay. All residents interviewed stated they experience routinely longer wait times around meals and bedtimes, where more residents need assistance at the same time. LPA interviewed seven (7) caregivers. All seven stated that they have been working when call times have exceeded what they all have understood as company direction to not exceed 15 minutes. On 2/15/24, when R1 was incontinent and waiting for assistance, interviews and records found that S1 was assigned to hall one. When R1 called for assist at 10:48, S1 was assisting another resident, R2, with bathing. Staff interviews did not provide specific reason why the 2 medication technicians (MT) or the other caregiver working (S2) in hall 2 did not respond timely on 2/15/24. All staff interviewed stated that reasons for delays in response times include but are not limited to insufficient staff (staff call offs), staff engaged with other residents/ duties and pager or pendant malfunctions. 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 with . Copy of this report and appeal rights provided.