complaint·August 28, 2023

Continue from LIC 9099) Both incidents were fully investigated by management who concluded the incidents did occur. Management took immediate corrective action by providing performance management to the staff involved. In addition, on July 27 and August 17, 2023, facility management provided two in-service trainings for all care staff on residents' personal rights, customer service, and personnel standards of conduct. Although, during interviews, most of the residents expressed satisfaction with the service being provided by the care staff, there was sufficient evidence to support the allegation that staff spoke inappropriately to residents. It was also alleged that staff did not attend to residents’ call buttons in a timely manner. During multiple interviews, residents consistently indicated that when they used their call button it took extended periods of time to get assistance from care staff. Some residents indicated they waited longer than one hour and at times even longer before getting the assistance they needed from care staff. A detailed review of some of the residents who raised concerns about the response time confirmed the response times were excessive. A review of the residents' care plans indicated they required assistance with activities of daily living, such as incontinence care, transfers due to limited mobility, and/or water/food service. Other more serious situations reported were residents needing assistance getting up after a fall. None of the residents reported serious injuries from these falls. The residents also indicated, that although not timely, they eventually received the assistance they needed from care staff. A detailed review of three different residents indicated their response times varied from 1 to 2 hours. According to the facility’s standard, the response time should be 15 minutes or less. A detailed review of the Call Button Excessive Response Report (CBERR) for a 2-month period indicated that in June 2023, there were a total of 867 calls that took longer than 15 minutes with an average of 58-minute response time. In July 2023, there were a total of 1,207 calls that took more than 15 minutes with an average response time of 45 minutes. Facility management indicated the CBERR was misleading. Management’s review discovered that some of the service calls were not cleared as complete in the system after care staff had attended to the resident’s needs. However, facility management acknowledged that this was an area of opportunity for improvement and had been providing training to staff to ensure calls were cleared as complete after servicing the resident. In addition, management stated that they identified staffing needs and scheduled staff accordingly to meet this goal. (Continue at LIC9099C) (continue from LIC9099C) Based on interviews with residents and staff and records review, there was sufficient evidence to support the allegation that staff did not respond to call buttons in a reasonable amount of time to ensure the health and safety of the residents. The Department has investigated the above-mentioned allegations and has found that there was sufficient evidence to corroborate the allegations. Therefore, these allegations are deemed to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. A Deficiency was cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D. A copy of this report, LIC 9099D, along with Licensee/Appeal Rights (LIC 9058 03/22) was provided to Executive Director, Angiano at the end of the visit.