Complaint·December 19, 2024

LPA Marrufo was able to interview nine staff members. All mentioned that if the administrator is not in the building then it will be the other directors or managers on duty who will be in charge. S2 mentioned that they would go to the Memory Care Director (MCD), Marketing Director or Business Office Director. It was communicated to S2 in person who to reach out too. S3 stated that they go to their immediate supervisor. S3 also shared that here (the facility) is like a family, when someone is not here, everyone is working together. S5 said that they have always been good, shared that they have never worked a day when the director wasn’t here. It is always a given that someone is here. S4 mentioned that it was never shared to him/her who was in charge of the whole facility when the administrator is gone but did mention that they go to the MCD. During the interviews, there were eight residents that were asked. R1 & R2 mentioned that the current administrator stepped up but they don’t remember if it was communicated to them who’s in charge if there is no administrator. R2 also shared that they have never experienced a time when there was no one in charge of the facility. They always get here. R8 said that there was a change in management but doesn’t know their name. R3, R4, R7 said they don’t know who’s in charge because it has never come up. R5 didn’t want to be interviewed. R6 is not able to answer due to cognitive issues. Based on records review, there were 5 people who has a designation of facility responsibility when Licensee or Administrator is not available. The current administrator was also appointed by the board on July 1, 2022. Regarding the allegation of Administrator (ADM) is not on the premises a sufficient number of hours. During the staff member interviews, seven staff members mentioned that they see the administrator every time they work. S1 said that he/she doesn’t know what time the ADM comes in due to the start time, but when S1 comes in the ADM is already in the facility. There are times when S1 leave and ADMs car is still there. ADM is still available on call in the evenings. If there are issues S1 reaches out and ADM always picks up. page 2 of 3 S2 said that they know ADM works in the mornings. S3 stated that ADMs work schedule is maybe 9 AM until 5 PM. ADM is here almost 5-6 days in a week. I am not completely sure. S4 shared that his/her shifts always used to change. The only time S4 would notice ADM gone would be maybe the weekends, but that was just the weekends. S5 mentioned that ADM is in the facility usually, 9-5. Give or take a few hours. If an emergency or something happens, they are here. When S5 comes here, they are maybe here 30 minutes before. For the allegation that Facility is not training staff, LPA Marrufo was able to obtain staff training records. 5 staff member have current CPR/AED/ First Aid Training, 6 staff showed 4 hours of Dementia Training. During the interviews, S1 shared that when he/she first got hired, the training received from the old nurse was not very much I felt like. Now, S1 is doing the training that should have done months ago, which is through Relias. The whole staff is doing that now. S7 mentioned that they have done first aid, dementia training, and fire drill training. S8 stated that they received hands on training by the old nurse. That was mostly hands on and watching videos. This new nurse just left and told us we had to train on Relias on our downtime because we have been pretty busy and haven’t been able to train. We went through 4 hours of med training where we check the meds 3 times and logging it into point click care after we give the medicine. The people who hand out the meds are supposed to use the point click care systems. If a care giver was trained by the nurse, then the care giver is supposed to be able to use the point click care system. Based on interviews and records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided.