Complaint·October 24, 2024

Interviews with 9 residents indicated that all require assistance with incontinence care and showering. 7 out 9 residents reported being left in soiled incontinence briefs for approximately 3 to 7 hours, stating that staff are aware of their condition but do not provide the necessary assistance. In addition, LPA Pascua conducted 3 unannounced visits on 07/16/2024 at 1:30pm to 5:00pm, 09/19/2024 at 10:00am-5:00pm, and 10/18/2024 at 6:30am-11:00am. During these visits, LPA Pascua observed a strong urine smell in consistently detected in hallways 2 and 3. Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This deficiency is addressed on the complaint investigation dated 10/24/2024 and a plan of correction has been established. Therefore, there will not be a LIC9099-D page for this substantiated finding. Allegation: Facility staff did not answer resident's call button It was alleged that facility staff did not answer resident’s call button. During the course of this investigation, this LPA reviewed facility documentation and conducted staff and resident interviews. 9 staff members were interviewed, 5 out of 9 acknowledged that they do not always answer call buttons immediately and that it may take some time to respond due to assisting other residents. They indicated that staff are expected to respond within 15 to 30 minutes, although they admitted that actual response times are often longer. In contrast, 4 out of 9 staff members denied any issues with responding to call buttons. Interviews with 9 residents revealed that 8 had used their call buttons but had stopped doing so due to delays in response. Many reported being left unanswered for extended periods, sometimes for hours or even overnight. A review of the facility’s call button log from May to August 2024 showed average response times of 3 to 6 hours in May and June, and 2 to 3 hours in July and August. Based on the information gathered, the facility staff did not answer the resident’s call button. Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. Allegation: F acility staff spoke inappropriately to resident(s) It was alleged that the facility staff spoke inappropriately to residents. During the course of this investigation, this LPA conducted staff and resident interviews. Based on interviews with 9 staff members, 5 out of 9 reported having heard colleagues speak inappropriately to residents. They noted that while many of these staff members have been fired or no longer work at the facility, some continue to engage in such behavior. 4 out 9 staff members denied ever hearing or participating in inappropriate communication. Interviews with 9 residents revealed that 8 out 9 have heard staff speak inappropriately, with 7 out 9 stating they have personally experienced inappropriate comments from staff, such as “This is why you are in a facility because you cannot help yourself”. Only 1 resident reported not having heard any inappropriate remarks directed at them or others. Residents also mentioned that many staff members who previously spoke inappropriately are no longer employed at the facility. However, it was noted that some staff occasionally make inappropriate comments in front of residents, even if not directed at them. Additionally, residents frequently hear inappropriate language in the hallways. Based on the information gathered, facility staff spoke inappropriately to residents. Based on the information gathered, facility staff spoke inappropriately to residents. Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. Allegation: Facility staff yelled at resident(s) It was reported that staff at the facility yelled at residents. During this investigation, the LPA conducted interviews with both staff and residents. Out of 9 staff interviews, 5 staff members indicated they had heard colleagues yelling at residents. They noted that most of those who yelled have since been fired or no longer work at the facility, although some staff still engage in this behavior. Conversely, 4 staff members denied having heard or participated in any yelling with residents. Interviews with 9 residents revealed that 8 of them had heard staff yelling. Only one resident reported no instances of staff yelling at them. Residents also mentioned that many of the staff who yelled no longer work there but acknowledged that staff sometimes yell in front of them, even if not directed at them. Additionally, it was noted that residents frequently hear staff yelling in the hallways. A review of facility town hall notes indicated that this issue has been addressed, with staff being encouraged to use walkie-talkies or phones for communication. Based on the gathered information, facility staff have yelled at residents. Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. An exit interview was conducted, appeals rights, and a copy of this report was provided to the facility at the end of this visit.