complaint·August 31, 2022

Regarding the allegation: Insufficient staffing. It was alleged that at the time the complaint was received, the facility had insufficient staffing due to staff quitting. Interview with Administrator on 06/14/2022, revealed that direct care staff/caregivers often call off or quit. Since direct care staff/caregivers call off or quit, it leads to the Administrator and other Administrative staff covering as caregivers, cooks and bus drivers. The Administrator stated that the Dining Service Director quit on the spot on 05/29/2022, which the Administrator began to act as a cook once a week until the replacement was found on 07/01/2022. The LPAs emphasized that due to the Administrator stepping in and acting as a direct care staff that it takes time away from completing Administrator duties. The Administrator explained that the facility is currently hiring, but the hiring process and training process is not fast enough. Additionally, four (4) out of six (6) residents interviewed on 06/14/2022, stated that the facility is short staffed and that the facility needs more staff. The resident interviews also revealed that the shortage in staffing is causing a delay in getting to the residents on time and meeting the resident’s needs. Staff interview on 06/14/2022, also confirmed the facility has a shortage in staffing and that direct care staff often work one (1) week and quit. Record review conducted on 06/14/2022 of staff schedules for June 2022, confirmed that staff often call off or quit since some shifts are crossed off or staff names are completely crossed off. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated. Regarding the allegation: Resident's incontinence needs not being met It was alleged that the facility staff did not meet Resident #1 (R1) incontinence needs. Interview with Administrator on 06/14/2022, revealed that the facility staff check on and reposition R1 every 2 hours per shift since R1 was bedridden. During the physical plant tour on 06/14/2022, LPA Peraldi observed a Two (2) Hour Reposition Log and a Bowel Movement Log for June 2022 taped onto R1’s wall near R1’s bed. The Two (2) Hour Reposition Log had missing dates or incomplete dates on 06/03/2022, 06/04/2022, 06/05/2022 and 06/06/2022. Additionally, on 08/04/2022, LPA Peraldi reviewed R1’s hospice records. Hospice records revealed that on 06/06/2022 hospice nurse found R1 saturated in urine, dry stool in groin area, and stool under draw sheet. Interview with hospice nurse conducted on 06/24/2022, confirmed that R1 was found saturated in urine and stool. Based on record review and interview , the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated. Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are cited: (Refer to LIC 9099-D). Exit interview conducted with Administrator. A copy of the report and appeal rights was provided. Regarding the allegation: Staff did not provide resident with clean linens. It was alleged that the facility does not clean residents’ linens. Interview with Administrator on 06/14/2022, revealed that the facility does not provide linens to residents upon admission and the residents bring their own linens. The Administrator explained that once residents are moved in and have linens, the facility does wash them. The Administrator stated that the facility does wash resident’s linens weekly and ensures that residents have clean linens. Interviews with staff and residents on 06/14/2022, confirmed that the facility does laundry once a week. None of the six (6) residents interviewed complained about the laundry services or about the uncleaned linens. During the physical plant tour on 06/14/2022, LPA Peraldi did not observe dirty or uncleaned linens. 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. Exit interview conducted with Administrator. A copy of the report and appeal rights was provided.