Complaint·March 22, 2023

Facility records show S2 had 7 hours of medication training in November 2019 and the Licensee did not provide any more current records. S2 does not have sufficient/current medication training. Facility records show S3 had 8 hours of medication training in 2019 and the Licensee did not provide any more current records. S3 does not have sufficient/current medication training. Facility records show S4 had 8 hours of medication training between July and August 2022, which does not meet the 10-hour requirement for new staff. Facility records show licensee had 7 hours of medication training in 2019, 3 hours of medication training in 2018, and did not provide any more current records. Licensee does not have sufficient/current medication training. Based on the evidence obtained, the allegation is Substantiated at this time. On the allegation: Facility has insufficient staffing. It was alleged that the facility sometimes has one caregiver on shift to handle all 14 residents in the facility. The reporting party notes staff quit mid-shift which left insufficient staff to care for and supervise the residents. LPA reviewed staff schedules for September 1, 2022 to September 18, 2022. LPA observed most of the days have two caregivers per shift. LPA observed one AM caregiver on 9/1/2022, one PM caregiver between 2:30 pm and 4:00 pm on 9/1/2022, and one overnight caregiver between 10:00pm and 6:00am. On 9/2/2022 there was one overnight caregiver, no overnight caregiver listed on 9/4/2022, and one overnight caregiver listed on 9/11/2022. Staff interviewed stated showers were done on time for the most part. Multiple staff noted if residents refused, the residents were not forced to shower and then staff tried again later. Staff interviewed indicated residents were toileted frequently, and residents with incontinence had their briefs changed on time and frequently checked. On the NOC shift, staff did rounds and made sure residents were clean and dry. Staff interviewed indicated they did not feel there were enough staff at the facility but everyone did their best to meet the residents’ needs. Staff interviewed indicated staff also have other duties including setting the table for meals, making beds, doing laundry, which takes time away from resident care. Staff interviewed indicated there were incidents where a staff fell asleep on shift and did not provide assistance. LPA reviewed the incident report for this incident, which indicated Resident 5 (R5) needed assistance and attempted to contact the awake-on duty staff but they did not respond. R5 contacted a family member, who came to the facility and entered through a window. Incident report states the staff was terminated for sleeping on the job. Staff also indicated one time a staff did not show up to their shift due to not setting their alarm and falling asleep, so there was only one staff on the shift instead of two. One staff interviewed indicated they worked in the kitchen, but during a COVID outbreak and decreased staffing, they assisted residents. Staff interviewed Please continue to 9099-C, Pg 3. indicated one person on the NOC shift did not feel there was sufficient staffing. Staff stated sometimes there was only one staff on other shifts as well, whereas usually there were two. Staff also indicated sometimes agency staff were brought in to supplement when needed. The facility scheduled staff based on residents’ needs, but if the staff were asleep and not working or did not show up to their assigned shifts, the facility had insufficient staffing. Based on the information obtained, the allegation is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D): Exit interview conducted. Copy of report and Appeal Rights issued at the time of the visit. interviews, staff told LPA that R3 and R4 sustained fractures. LPA did not find any incident reports indicating residents sustained a fracture. There was no record or recollection of R4 falling or sustaining a fracture. Based on the information obtained, there is insufficient evidence to support the allegation that due to staff neglect, resident fell while in care resulting in fracture. Therefore, the allegation is Unsubstantiated at this time. On the allegation: Uncleared staff caring and supervising residents in care. LPA reviewed a staff roster and a list of fingerprint clearance for this facility. LPA observed during the time of this complaint, S1 was not cleared or associated to the facility. LPA observed that S1 was previously associated to the previous license for this facility. The facility underwent a change of ownership, and records show S1 was disassociated from the facility on 2/18/22, the day that CCL processed the closure for the previous facility. During the closure process, S1 was not associated to the new/current facility, per CCL’s process. It appears an error or technical glitch occurred, as no documentation shows the Licensee tried to disassociate S1. S1 has already been reassociated to the facility. Based on the information obtained, the allegation is Unsubstantiated at this time. On the allegation: Facility is not reporting incidents. It was alleged the facility did not report incidents of residents striking other residents. LPA reviewed incident reports for 2022 and observed two incidents where there were resident on resident conflicts, on dates 4/29/2022 and 7/6/2022. LPA interviewed staff about serious incidents, and was told R1, R3, and R4 sustained fractures. CCL received an incident report for R1’s fracture. CCL did not receive incident reports for fractures for R3 or R4, but LPA based on the investigation, determined there was no evidence or documentation to show R3 or R4 sustained fractures. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report issued at the time of the visit.