complaint·February 4, 2025

(Continued from LIC9099 p.1) Staff interviews revealed that one staff member was previously reprimanded for providing resident information to Responsible Parties who were not associated to their loved ones. Staff interviews further revealed that management held a meeting with staff informing them not to provide facility information to staff who no longer work at the facility. The staff members suspected of breaking confidentiality denied providing resident information to outside parties. However, the investigation revealed one of the staff member's claims to be untrue, as outside source documents showed this staff member to be specifically named as the source of information by a former staff who no longer works at the facility. Confirmation was made with the resident's responsible party, who confirmed that they did not authorize the resident's personal information to be shared with the former staff. Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation occurred and is therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Executive Director Chris Tharp, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from LIC9099 p.1) The staffing model was made based on the acuity level of residents, and the Medication Technicians (Med Techs) on each shift were an extra person to assist when needed. Management informed that the facility intentionally staffed above the recommended number, based on acuity. Management also informed that the facility had experienced staffing issues from common seasonal communicable diseases that resulted in staff call-outs, and ongoing efforts had been made to over-hire to ensure shifts were completely covered when staff called out. Additionally, management informed that the facility spent a significant amount of money in December 2024 for Agency/Registry staff and in overtime costs to meet the recommended staffing numbers. Outside source interviews were conducted regarding the allegation. One outside source expressed that the facility needed more staff, however, they did not advise of any health or safety issues observed as a result of low staffing, informing that it was more of an inconvenience for visitors to have to wait for things. Additional outside sources did not respond to requests for interview. During unannounced facility visits LPA observed caregivers, Med Techs, and activities staff assisting residents with Activities of Daily Living (ADLs), medications, and group activities. LPA observed visitors requesting help from staff, and staff either helping right away or communicating when they would be able to help. LPA did not observe any health or safety issues for residents, or basic care needs that remained unmet during facility visits. Review of facility records corroborated staff statements regarding staffing models and additional staff expenditures. Payroll invoices dated 12/01/2024 to 01/15/2025 showed that $23,792.04 was spent on overtime in December 2024 and $8,352.35 was spent between January 1-15th 2025. Between 12/07/2024 to 01/24/2025, $3,053.04 was spent on agency/registry staff. A Rounds Schedules document showed that residents were grouped into 3 or 6 "rounds" during AM, PM, and NOC shifts with the assigned Med Tech noted. Regarding the allegation, "Facility entryway was in disrepair", it was alleged that the entryway from the reception area to the resident area remained in disrepair, causing a tripping hazard, and was unaddressed by the facility. Staff interview revealed that in early December 2024 the flooring in question was seen to be expanding upward, causing a hazard. Staff interviews revealed that the facility took action when the issue was identified, removing a portion of the floor to assess the issue. Staff interviews further revealed that contractors were hired to identify the source of the issue, which was identified to be a water leak. (Continued on LIC9099-C p. 3) (Continued from LIC9099-C p.2) The area was treated for potential mold and temporary planks were placed, with caution signs next to them. Additionally, management informed that approval was pending from the corporate office for the floor to be fixed by a contractor. During the investigation management notified LPA that the approval was granted and a timeline was in place for contractors to replace the floor. Outside sources corroborated staff statements. The contractor named by the facility to address the water leak confirmed the information, informing that an irrigation issue was found. The contractor noted that no mold was found during the assessment. Facility records corroborated staff statements regarding the entryway repair. An invoice dated 12/31/24 listed the contractor assigned to repair the flooring with an itemized list of tasks, including the removal and disposal of the old flooring, and replacing the floors. During an unannounced facility visit on 01/10/25 LPA observed a temporary board covering the floor with caution signs; LPA confirmed that no resident or visitor had tripped on the board or been injured. During an unannounced facility visit on 01/21/2025 LPA observed the temporary flooring to be replaced with a thinner board that was nearly flush with the floor. During an unannounced facility visit on 02/04/2025 LPA observed the flooring to be under active repair by the named contractor. The evidence shows that the Licensee took timely action to repair the flooring once it was discovered to be in disrepair. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Chris Tharp, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.