Complaint·August 31, 2021

Residents' care levels range from Level 2 to 6. At this time facility has 4 res. Level 2, 11 res. Level 3; 10 res. Level 4, 9 res. Level 5, and 5 res. Level 6. Per care plans there are 32 res. w/ fall concerns; 26 need some kind of assistance w/ toileting; 29 needs some kind of assistance and 6 total assistance w/ meals; 9 need assistance w/ transfers and 4 of them is 2 people assist; 27 need diaper change; 5 on hospice; 37 need status check 4 times per shift and 3 need 8 times per shift. In regard to shower schedule, facility schedule shows the following for residents Monday AM 10 & PM 3, Tuesday AM 8 & PM 10, Wednesday AM 10 & 3 PM, Thursday AM10 & 0 PM, Friday AM 9 & 8 PM, Saturday AM 6 & 6 PM, Sunday AM 9 & 2 PM; with 4 residents being 2 people assist. Facility has 4 caregivers on shift to conduct showers, status checks, meals, diapers, toileting, grooming and all the other needs that my occur on each shift. During interviews with staff and family members/POAs, LPA learned that there is a concern about facility being understaffed and staff not being able to meet all residents needs. Staff stated that at times caregivers need to attend alone when helping with a 2 people assist resident. In addition, during visit & Brandee R. ED interview on 8/25, executive director (ED) stated that during meeting with families/POAs, she tells the POAs that they are not able to find caregivers and agency are not having staff available and that the family members know about this before they actually move in. During visit on 8/25/21, there were 3 caregiver staff & 1 agency staff with a med tech. In addition, during today's visit on 8/31/2021 at 8:43 AM while LPAs were waiting for office staff to close the complaint investigation resident R2 came into conference room asking for help. Resident R2 had a shirt on, no pants, and a heavy diaper. (pics on file) Resident R2 urinated at the conference room door. LPA walked with resident to medication room. There was no staff from conference room to dining room/medication room. Based on investigation facility has insufficient staffing to meet resident's needs. (see confidential name list, LIC 812s, LIC 809-D) Department is providing facility with updated Home Care Agency. Continue LIC 809-C According with complaint allegation “Insufficient staffing to meet resident's needs.” there were related observations made during visit. Based on LPAs' observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. In addition, facility residents have had innumerous falls w/ some having some kind of injury. Resident R1 on Hospice had a fall that resulted on a broken hip injury that occurred on 3/22/21 AM. Based on LPA interviews and documentation review, LPA wasn’t able to prove or disprove that fall with injury occurred due to neglect/lack of supervision. A finding that the complaint allegation of “Neglect/lack of supervision resulted in resident fall and injury.” is unsubstantiated meaning that although the allegation 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. ****Department is requiring a mandatory informal office meeting that will be scheduled. No deficiencies cited during this inspection.