complaint·October 20, 2023

continue from LIC 9099 During multiple interviews with staff, residents, and outside sources, it was consistently indicated that the facility did not have sufficient staff to meet resident’s needs. During interviews with multiple residents with total assistance needs for all activities of daily living including toileting, it was consistently indicated residents were left with soiled briefs for extended periods of time. The residents consistently stated that there were times they did not get incontinence care for 4 to 5 hours during the day shift, and at times even longer. The same concerns were voiced during interviews with outside sources. In addition, interviews with outside source medical providers indicated that some total assist residents who were bedbound and needed to be repositioned every two hours, as required in their service care plans, did not get repositioned or changCed from 10 p.m. until 5 or 6 a.m. the following morning. During the investigation, an incident when a total assist resident was left in a soiled brief for more than 13 hours was disclosed. On Thursday, October 12, 2023, at 10:24 a.m. an outside source found a resident with an extremely soaked brief marked with “9:00 p.m.” and the staff member's initials. The staff member who marked and initialed the brief confirmed the information was correct. A picture of the resident’s soiled brief was reviewed during the investigation. Multiple interviews with staff and residents indicated there was a high level of employee turnover since the facility change of ownership that took place on March 7, 2023. Management indicated that seven (7) care staff left the facility in early September 2023. In addition, during interviews, staff indicated that although they were working double shifts to provide adequate coverage to meet the needs of residents, at times there were no available caregivers to work during unforeseen callouts. Based on the review of the work schedule for the months of September and October 2023 it appeared that for the most part, there were enough caregivers scheduled to work per shift. However, there were times when caregivers called out and it wasn't clear which caregiver provided coverage on that day or if coverage was provided. The Executive Director indicated that the facility had a current contract with a temporary agency for caregivers. However, according to management, the facility did not employ caregivers from the temporary agency because they were able to meet the needs of the residents with the current staff working double shifts. Management indicated that October 13, 2023, was the first time the facility did not have enough caregivers and employed caregivers from the temporary agency to provide coverage during the night shift. (continue at LIC9099C) Continue from LIC 9099C Based on observations, records review, and interviews with staff, residents, and outside sources, there was sufficient evidence to support the allegation that staff did not meet the resident’s incontinence care needs. The Department has investigated the above-mentioned allegations and has found that there was sufficient evidence to corroborate the allegations. Therefore, this allegation is 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 plan of correction was developed with the Resident Services Director, Tillman. A copy of this report, LIC 9099D, LIC811 Confidential names along with Licensee/Appeal Rights (LIC 9058 03/22) was provided to Resident Services Director, Tillman, at the end of the visit.