complaint·June 20, 2022

LPA Martinez reviewed 01's January and February 2022 Medication Administration Record (MAR). It was determined medications were not being administered on some day in January and February. R0 Admission care plan includes providing and administering medication. As result, the facility did follow R0's care plan. During the investigation, LPA Martinez toured the facility. It was learned the facility does not have adequate staff to meet the needs of the residents in care. LPA Martinez observed a resident activity on June 6, 2022. LPA Martinez observed one activity caregiver and 14 residents. At times an additional caregiver entered the activities room, but the caregiver did not stay and assist with the activity. Throughout the duration of the activity, residents were eating each others snacks. Residents were also drinking each others water while the assigned activity caregiver was completing other tasks. The assigned activity caregiver had to stop her current task, and stop the residents from eating and drinking each others snacks and water. Resident 1 (R1) attempted to transfer onto a chair, and half his bottom was off the chair. The assigned activity caregiver stopped her current task to help R1. During this time, the other residents were not supervised. Resident 2 (R2) requires additional emotional support and attention. Throughout the activity, R2 continued to ask for help and asked for her hand to be held. R2's needs were not being met due to the assigned activity caregiver being busy with other tasks. LPA Pascua approached R2, and asked R2's if she needed any assistance. Additionally, resident 3 (R3) was sitting at the outside patio unsupervised. R3 was sitting on a wheelchair directly under the sun. LPA Martinez observed R3 from the activity room at 11:02 AM. LPA Martinez did not observer any care staff check on R3. At 11:13 AM, R3 woke up and pushed himself to the activity exterior room door. Residents tried to open the door for R3. Once the assigned activity caregiver became aware of this incident, the assigned activity caregiver stopped her current task to open the door for R3. The assigned activity caregiver did not offer R3 a snack or drink. In addition, the assigned activity caregiver did not encourage R3 to participate in the activity. Continued... R3 wandered off into the facility common area. During this time, resident 4 (R4) 02 nasal tubing was not on correctly, and LPA Martinez had to inform the assigned activity caregiver to assist R4. The assigned activity caregiver stopped her current task to help R4. The activity ended at 11:30AM and ambulatory residents were escorted to the dinning room. The following four non-ambulatory residents had to wait for other caregivers to assist them to the dinning room: Resident 5 (R5) was assisted at 11:35 AM. Resident 2 (R2) was assisted at 11:38 AM. Residents 6 and 7 (R6/R7) were assisted at 11:41 AM Moreover, LPA Martinez and LPA Pascua observed lunch in the facility dinning room. There were two kitchen staff working on this day, and caregivers were serving meals to residents. In addition, one kitchen staff 1 (K1) was assisting with serving meals to residents. It was also reported on June 6, 2022 there were two caregivers serving meals, and Kitchen staff (2) duties included, preparing meals, cooking meals, serving meals, washing dishes, cleaning kitchen. As a result, K2 was not able to complete some tasks. LPA Pascua was in the dinning room during lunch, and observed no caregivers from 12:04 PM to 12:12 PM. During this time, R2 did not have a drink. LPA Pascua assisted R2 by getting R2 a drink. As a result of LPA Martinez and LPA Pascua's observations, the facility does not have sufficient staff to meet the needs of the residents in care. The Department finds the allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Kirk Goodin. A copy of this report, LIC 9099-D, and appeal rights were given to the facility.