complaint·October 16, 2024

continued from 9099... Complaint alleges licensee does not ensure adequate staffing. Complainant states not enough staff to properly transfer residents requiring assistance. Complaint alleges Personal rights. Complainant states residents are not allowed to go to their bedrooms and residents remain in wheelchairs for extended periods of time. During investigation, LPA interviewed seven [7] staff. Five [5] out of seven [7] employees state they need help and don’t have enough staff to meet residents' care needs. Additionally, seven [7] out of seven [7] staff say they do not get breaks because there is not enough staff to cover. Five [5] out of seven [7] staff say at times, there is only one person working in MC1. Only one staff being present could be due to staff lunch or as some staff reported, in the most recent summer months only one person was actually working in MC1 per shift. Additionally, one [1] out of one [1] witness states that there is sometimes only 1 person in MC1 during a shift, but definitely only one during lunches. Three [3] out of seven [7] staff and one [1] out of one [1] witness state that the residents remain in their wheelchairs for extended period of time due to not having enough staff to transfer from wheelchair to the recliners in the living room of MC1. During investigation, LPA reviewed staff schedule. Staff schedule shows that no more than 2 people are assigned to MC1 at any given time, not including coverage during staff lunches. However, LPA review of residents’ physician reports and care plans of the ten [10] residents residing in MC1 shows that: · 9 Need a total assist with Bathing, · 7 Need a total assist with Grooming · 10 Need a total assist with Dressing · 10 Need a total assist with Toileting · 4 Need a total assist with Transfers · 10 Need total assist with Medications · 7 Are identified as a fall risk Continued on 9099C(2)... continued from 9099C... · 1 Need a stand-by assist with Bathing, · 3 Need a stand-by with Grooming · 4 Need a stand-by with Transfers · 4 residents in MC1 require a 2 person assist as indicated by their care plans and as indicated by staff. Based on LPA’s observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Complaint alleges resident needs are not being met. During investigation, Administrator advised the method by which residents alert staff that they need help or require assistance is through a pendant call button system. Each resident is assigned a pendant. When a resident needs help or assistance with a care need, they push the button on their pendant in order to alert staff to their need. LPA review of pendant log shows that between 6/30/24 and 7/2/24 residents pushed their pendant call button 36 times. Of those 36 times, the wait times until someone arrived to help were: · 8 waited at least 15 minutes, · 11 waited at least 30 minutes, and · 16 either never got a response or there was an error in the pendant log system. LPA review of pendant log shows that between 9/1/2024 and 9/27/2024 residents pushed their pendant call button 621 times. Of those 621 times, the wait times until someone arrived to help were: · 94 waited 15 minutes or more, · 56 waited 30 minutes or more, Continued on 9099C(3)... Continued from 9099C(2)... · 20 waited at least 1 hour, · 7 waited more at least 2 hours, · 3 waited at least 3 hours, · 1 waited at least 5 hours, · 1 waited at least 6 hours, and · 126 either never got a response or there was an error in the pendant log system. Additionally, the pendant call button/pull cord was pushed in Memory Care #1 bathroom or rear door a total of 6 times, where the wait times show as: · 1 for 21 hours, · 1 for 14 hours, · 1 for 7 hours, · 2 for 5 hours, and · 1 time either they never got a response or there was an error in the pendant log system. During investigation, on 7/12/2024 at approximately 10:30am, LPA entered the room of a resident (R6) for the purposes of conducting an interview. Resident informed LPA she has been pressing her pendant for the past 45 minutes and no one has come. LPA then pushed resident's pendant and set the stopwatch timer. LPA observed a caregiver to arrive to answer the pendant 24 minutes after LPA pushed the pendant. During investigation, on 9/27/24 LPA interviewed resident (R4). While interviewing R4, LPA asked to push their pendant in order to confirm caregivers’ response time. LPA waited for 32 minutes. LPA did not observe staff to address the pendant alert while present in the room. Continued on 9099C(4)... continued from 9099C(3) Based on LPA’s observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given .