Complaint·January 24, 2024

During today’s visit, interviews conducted revealed that staff are sometimes unable to answer the phone because they are assisting residents with brief changes, showers, medication distribution, and other basic services. Staff 1 (S1) stated when the calls go to voicemail, the staff (caregivers, medication technicians, etc) on duty do not have access to retrieve the voicemail messages. S1 further stated when S1 takes a call and cannot provide information, the caller’s name and phone number are taken in a message book then S1 gives it to a “corporate person” when they come to the facility. During today’s visit, LPA observed the Business Office Director and the Regional Director of Operations were not available at the facility. Staff stated the Business Office Director was at the facility for approximately three hours on Monday, 1/22/2024. Staff further stated the Regional Director of Operations was at the facility for approximately one hour one day last week, possibly Tuesday, 1/16/2024 or Wednesday, 1/17/2024. Based on interviews conducted, records reviewed, and observations made, the allegation that due to lack of staffing, the facility staff are not answering the facility telephone is Substantiated at this time. On the allegation, staff did not notify authorized representative of an incident with a resident, Reporting Party (RP) stated RP learned that Resident 1 (R1) was taken to the hospital emergency room on 12/4/2023 when RP received an invoice from the medical emergency agency about three weeks after the emergency transport. During today’s visit, LPA obtained medical discharge papers and care notes indicating R1 was sent to the hospital via a call to 9-1-1. At approximately 2:34 pm, Staff 2 (S2) stated on 12/4/2023, R1 was sent to the hospital emergency room the evening of 12/4/2023. S2 further stated R1 returned from the hospital emergency room that same evening. LPA reviewed LIC624 Serious Illness/Serious Injury Reports submitted by the facility to Community Care Licensing Division (CCLD) and determined that CCLD did not receive LIC624, Serious Illness/Injury Report notifying CCLD of R1’s hospital visit. At the time of the visit, no record of an incident report was available reporting R1’s emergency room visit to R1’s responsible parties or to CCLD. Based on interviews conducted and records reviewed, the allegation that facility staff did not notify an authorized representative of an incident with a resident is Substantiated at this time. The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.