complaint·July 29, 2021

1 out of 15 residents does not need restroom assistance or wears diapers. 0 out of 15 residents on hospice, 8 out of 15 residents are non-ambulatory, 1 out of 15 residents has dementia and 0 out of 15 residents are bedridden or have wandering behavior. 10 of 15 residents cannot leave the facility unassisted. 5 out of 15 residents need transfer assistance and 1 out of 15 residents need a 2-person assist. 3 of out of 15 residents have special health care needs. 9 out 10 staff stated, there is enough staff to meet the resident’s needs, but sometimes the facility experiences staff shortages. Due to frequent call outs, it is challenging to provide care with only 2-3 staff members. 9 out of 10 staff stated, the facility has support from backup staff at other programs, and staff members also volunteer to cover shifts for overtime. The staff are not obligated to work overtime. The Executive on Duty (EOD) and the Program Administrator are obligated to cover open shifts if not fulfilled. 3 out of 10 residents stated that incidents can occur if the facility is short staffed or fully staffed, and it depends on the resident’s behavior. 1 out of the 8 staff stated that when 2 caregivers are helping a 2-person assist, the 3 rd caregiver is solely responsible for 14 residents, for about 10-15 minutes. All staff stated the facility does not call the fire department for lift assistance, because the facility has a Hoyer lift and an Easy lift. 9 out of 10 staff stated that the residents are never left unattended or unsupervised in the facility. 1 staff stated, there is not enough staff at the facility, and when the shift only has 2-3 staff, sometimes resident must wait for assistance. When 2-3 staff work a shift, the residents are prioritized, and some residents must wait unattended until assisted. 3 out of 10 residents stated that they are treated good by the staff, but the facility is understaffed. 7 out of 10 residents stated that the staff treat me good and the facility has enough staff. 9 out of 10 residents stated that the staff quickly respond to their call button or respond within a reasonable amount of time. 1 out of 10 residents stated they wait a while for staff but cannot recall how long the wait is. LPA reviewed the December 2019 call log, and the log indicated that staff responded to the residents within minutes. The call log for the weekend shifts in December 2019 also indicate that staff primarily respond to the residents within minutes, and a few calls were longer than 10 minutes. All residents stated that if they’re pain, the staff promptly provide PRNs, Tylenol or other prescribed medication. 1 out of 2 family members stated, the facility has enough staff to assist residents, and a staff member can always be found to answer questions. The family member has called the facility and the staff do not answer and stated because the staff is busy and that is understandable. According to the family member, the staff responds timely to the resident call button and when providing PRNs or Medications. The staff never leave the residents unattended in common areas. 1 out of 2 family members stated the facility has enough staffing during the week, but also stated that there is not enough staffing on the weekend. The staff cannot assist R1 on the computer due to the lack of staffing, and the family member never received a call back from the facility after leaving 2-3 messages on the weekend. According to the family member, the staff never leave residents unattended and R1 does not wait long for assistance. The Administrator stated that there is enough staff to take care of all the residents. The facility also reallocates staff from other programs to ensure there is enough coverage and maintain a level of safety. The Administrator stated it is realistic to provide adequate care with the staff. The busiest time at the facility is from 8am to 8pm, and during this time there are 3-4 staff, 1 LVN and additional backup from the other programs. The facility also has 1 on 1 caregivers from outside agencies to assist during the day and night. The NOC shift consists of 2 caregivers, back up staff and the EOD is on standby. The NOC shift has fewer staff because residents are sleeping, and it is less busy. Staff members have frequently called out in 2019, 2020 and 2021. There are regular staff members that pick up double shifts, and double shifts are not mandatory. The EOD is also available to fulfill open shifts. The nurses do a full body check twice a month, and the staff check the residents anytime they perform hygiene duties. Administrator stated the residents receive medication on time, the facility does not call the fire department for frequent lift assistance and residents are never left unattended. Based on the information gathered from interviews and records reviewed the allegation is deemed unsubstantiated. Exit interview, report emailed.