complaint·December 19, 2024

It was also alleged that it’s difficult for staff to respond to residents call buttons in a timely manner due to the low number of staff who work the night shift. It was stated that instead of the response times being between 5-10 minutes, it has increased to 20-30 minutes On 05/29/2024, 3 residents were interviewed. Based on resident interview, 2 out of 3 residents states that the facility does not have enough night supervision. It was stated that there is only 2-night shift staff for the whole building. 4 staff members were interviewed throughout this investigation. Based on staff interview, 2 staff states there is not enough night supervision staff. 2 staff states there is only two staff who work the NOC shift. It was stated that there were some days where only one staff would work the NOC shift. S3 stated that there was a time before S3 was hired when there was only 1 NOC shift staff working in Prom and Plaza. Based on record review, the NOC staffing schedule in May 2024, it shows only 1 caregiver scheduled in the Prom/Plaza (Assisted Living) section of the facility on Sunday and Mondays. Based on staff interview, the standard NOC staffing schedule should be 2 staff in the prom and plaza area. Based on resident interview, 2 out of 3 residents states a negative experience with the facility’s pendant system. R1 states a time where he/she was sitting on the floor for about 45 minutes before a staff responded to his/her pendant call. R2 states that no one comes for about 45 minutes. R2 states in the morning, it takes about half an hour to an hour for staff to respond. Based on review of R1’s pendant call logs, it shows that in May 2024 there were 88 calls that had a response time of 10 minutes and more. 33 out of 88 calls had over a 30-minute response time. 26 out of 88 calls had over a 15-minute response time between the hours of 10:00PM – 6:00AM. Page 2 of 3. Based on review of R2’s pendant calls logs, it shows that in May 2024 there were 55 calls that had a response time of 10 minutes or more. 16 out of 55 calls had over a 30-minute response time. R2 did not press the call button between the hours of 10PM – 6AM. Based on interview with the General Manager, the expectations is for staff to respond to the residents call button within 15 minutes. The Department has investigated the above allegations. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegations are substantiated. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with General Manager, Billy Mitchell and a copy of the report and appeal rights were provided. Page 3 of 3. On 06/12/2024, 3 residents were interviewed. Based on interview, 3 out of 3 residents stated the bedsheets are self-provided and staff assist with washing their bedsheets. 3 out of 3 residents denied being left in bed without bed sheets. Based on interview with R1, R1 denied being left in bed without bed sheets. R1 states that staff has changed his/her sheets in the middle of the night because he/she wet the bed, but staff did place another set of sheets on his/her bed. R1 states that some of the staff are not able to change his/her sheets in the middle of the night but R1 stated that staff always provided him/her with bed sheets. On 06/12/2024, LPA Dolores observed R1’s bed had bedsheets. A witness (W1) was interviewed. W1 stated that R1’s bed sheets were self-provided. W1 states a time where he/she observed R1’s bed was made but upon checking the bed, W1 observed R1’s bed sheets were stained with urine and blood. W1 thinks that the night staff might have left R1 in bed with the urine and blood-stained sheets because the staff was not able to lift R1. W1 denied observing R1 without bed sheets. The Department has investigated the above allegation. Based on interview and observation the above allegation is unsubstantiated. An unsubstantiated finding indicated that although the allegation is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided.