Complaint·December 27, 2024

Report continued from LIC9099... On 11/26/2024, LPA Cortez starting at 1:00 p.m. conducted four (4) resident and two (2) staff interviews. On 12/02/2024, between 11:40 a.m. and 4:30 p.m. LPA Cortez conducted two (2) staff and five (5) resident interviews. On 12/13/2024, LPA Cortez, between 01:00 p.m. and 4:15 p.m. interviewed two (2) staff, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 12/16/2024, between 10:30 a.m. and 4:30 p.m., LPA Cortez conducted five (5) staff interviews and obtained copies of pertinent documents relevant to the investigation. On the allegations, “Staff did not ensure residents medication was dispensed in a timely manner, and Licensee does not ensure facility has sufficient amount of staff to meet the care needs of residents”; it is the concern of the reporting party that approximately around or on 10/10/2023, staff took three (3) hours to dispense morning medication to Resident 1 (R1) and Resident 2 (R2) and that the facility does not have enough care staff to provide care for all of the residents needs in a timely manner. To investigate the allegations, the LPA conducted interviews and file review. Staff interviews revealed that MedTechs (MTs) are trained to document the time that a resident’s medicine is prepared and document after the medicine has been administered. The MT will log on to their online system and check what residents they will be assisting with medications. They will select the resident that they will be dispensing medications, after the medication has been prepared and is ready to be given, they will press the “PREP MED” button, and give the medication to the resident. After the medication is given, the MT will go back to their online system and press the “PASS MED” button to chart that the medication has been given. Staff revealed that there is certain times that after a medication has been given a MT may be called or stopped to assist with other things and may not chart right after the medication was passed. A review of R1’s Electronic Medication Administration Record (eMAR) revealed that on 10/12/2023, two of R1’s medications that were scheduled for 7:00 a.m. and one medication that was scheduled for 8:00 a.m. were documented as prepped at 11:27 a.m. and charted at 12:12 p.m. A file review revealed that R2 is no longer at the facility, and the LPA could not view R2’s eMAR. Furthermore, staff revealed that they have heard residents complained that they do not receive their medication on time and have heard other staff over the walkie talkie report that certain resident is still waiting for meds and has been an hour. Report continued on LIC9099-C.... Report continued from LIC9099... Interviews conducted with care staff and MedTechs revealed that a full staffed morning shift is four (4) caregivers and (2) MedTechs (MT) in Assisted Living and three (3) caregivers and one (1) MT in Memory Care. Six (6) out of eight (8) staff that were working at the community during 2023, recall or have knowledge of the community being understaffed, including in October of 2023 during the time the complaint was submitted. A staff revealed that there has been plenty of times that there have only been two (2) staff on the floor, they further revealed that there was one shift where they were the only staff in all four (4) floors in Assisted Living. The staff also revealed that it was noticeable that there were times that R1 had peed on themselves because staff did not get to them on time due to there not being enough staff. Other staff revealed that residents brought up concerns of staff being understaffed in the town hall meetings many times. Many staff revealed that the community is currently doing a lot better this year and believe their workload is manageable, however their workload can become not manageable if staff calls out and management does not have anyone to cover their shift. Additionally, staff revealed that their workload was not manageable in 2023. Staff revealed they often had to take on other’s responsibilities due to lack of staff and felt stressed and rushed. Furthermore, staff revealed that they felt bad for the residents during that time, because they were not getting the good service that they deserve. Two residents revealed that in 2023, the community was understaffed, and it was noticeable as staff would be in a hurry to assist, there were times they had to wait as much as two (2) hours for assistance. Based on the information gathered through interviews and file review, although staff interviews revealed that staffing has improved, at the time the complaint was submitted the community did not have adequate staffing to assist resident with care needs. File review revealed that medications for R1 that were scheduled for 7:00 a.m. and 8:00 a.m. were documented as prepped until 11:27 a.m. and charted until 12:12 p.m. making them over three (3) hours late. Therefore, the allegations, “Staff did not ensure residents medication was dispensed in a timely manner, and Licensee does not ensure facility has sufficient amount of staff to meet the care needs of residents” are deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued. Report continued from LIC9099... On 11/26/2024, LPA Cortez starting at 1:00 p.m. conducted four (4) resident and two (2) staff interviews. On 12/02/2024, between 11:40 a.m. and 4:30 p.m. LPA Cortez conducted two (2) staff and five (5) resident interviews. On 12/13/2024, LPA Cortez, between 01:00 p.m. and 4:15 p.m. interviewed two (2) staff, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 12/16/2024, between 10:30 a.m. and 4:30 p.m., LPA Cortez conducted five (5) staff interviews and obtained copies of pertinent documents relevant to the investigation. On the allegation, “Staff has inappropriate conversations with other facility staff in front of residents,” it is the concern of the reporting party that Staff 1 (S1) yells and uses foul language at the care staff while in presence of the residents and visitors. The RP further revealed that they personally have never witness S1 yell or use foul language in front of the residences. Staff and File review revealed that S1 no longer works at the community. All staff interviewed regarding the allegation revealed that they have never witness or heard any staff speak inappropriately or yell in front of the residents. All residents interviewed revealed that they have not heard staff speak inappropriately in front of them. Based on interviews, there is insufficient evidence to support the above-mentioned allegation. The allegation, “Staff has inappropriate conversations with other facility staff in front of residents,” is unsubstantiated at this time. Exit interview conducted. A copy of today's report was provided.