complaint·April 25, 2022

Regarding the allegation " personnel were not trained for the job(s) assigned to them:" Interviews with Management revealed that during the time period surrounding the complaint allegations, the facility was experiencing staffing shortages. The Administrator had called the LPA and let her know there were no dining room staff, the cook had also left the facility. During that time period, other facility staff, including management, helped with cooking while the facility searched to hire new cooks. Administrator stated to LPA that they were not trained to work in the kitchen and the management staff were filling in and had made sandwiches for the residents. Additionally, the management staff cooked the holiday meal for the residents. Another staff interview revealed they were "thrown into the kitchen to cook." Staff interviews revealed that while there is a plan for training staff prior to working in the facility, due to lack of available staff, staff are asked to cover shifts in other departments prior to receiving the appropriate cross-training. Based on interview, the allegation that "personnel were not trained for the job(s) assigned to them is deemed SUBSTANTIATED at this time. Regarding the allegation " Facility did not maintain adequate staffing to meet resident(s) needs:" LPA reviewed staffing records provided for December 2020. The following was found: only one caregiver working from 6:00AM-8:31AM on 12/30/2020. A second caregiver arrived at 8:31AM and a third caregiver arrived at 10:02AM. The facility's Mitigation Plan indicated staff were not to be shared between Memory Care and Assisted Living, but on 12/30/2020, there was only one caregiving staff working for all residents in the building. Additionally, on 12/20/2020 and 12/17/2020 during the NOC shift, there was only 1 caregiver working overnight. Interviews with staff revealed the facility was short staffed due to staff calling out for their scheduled shifts. Sometimes management would come in and cover the shifts, but not always. When caregivers call out, the medication technician can help out with caregiving tasks. At the time of the complaint, caregiver duties included assisting residents with ADLs, showering residents, and doing laundry for the residents, as well as light housekeeping duties. Staff interviews revealed that 2 or 3 caregivers for Assisted Living and one for Memory Care are scheduled during the am and pm shifts and one on each side for the NOC shift. According to staff, there were 3-4 residents that required a 2-person assist and at the time of the complaint there were 53 residents in the facility. One resident indicated "some days they don't have enough people" which results in long wait times for the residents who require assistance. Therefore, based on interview and record review, the allegation "facility did not maintain adequate staffing to meet resident(s) needs" is deemed SUBSTANTIATED at this time. Report continued on LIC 9099-C Regarding the allegation " resident(s) call lights are not being answered:" LPA Dulek reviewed SMARTcare records for call lights during the time period of 12/31/2020 - 1/7/2021. The following was noted: over 100 times during the one-week period, response time was greater than 15 minutes. An additional 16 times the call was marked as "response required but not received...This alert was never responded to." Staff interview revealed that staff are required to respond to calls within 2-3 announcements, which allows for approximately 15-minute response. Staff stated that sometimes if all staff are busy assisting other residents, residents calling for assistance need to wait longer. Resident interviews revealed that often residents are waiting for half-hour to 45 minutes for assistance and that "it depends on the day how long the response time is. Some days they don't have enough people." 5 of 5 residents interviewed agreed that call response times vary and are often too long. Therefore, based on record review and interview, the allegation that "resident(s) call lights are not being answered" is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D) Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided via email.