It was reported that a resident had not showered for four days.

LPA reviewed Resident 1’s (R1) Health Evaluation/Assessment and Service Plan with an effective date of 7/10/2023 which says that R1 requires physical assistance with showering and wants to shower 2 times per week with an additional 5 showers per week (daily). Staff are to provide physical assistance with showers per the shower schedule. The facility uses Point-Click-Care to log all ADL assistance provided to residents. R1 moved into the facility on 07/03/2023. LPA reviewed logs for the month of July 2023. Showers are logged in two places in Point-Click-Care, 6:00 am to 2:00 pm shift logged showers for R1 on all days with a few exceptions. NOC shift logs show showers completed on 07/03/23 through 07/05/23. The shower log is blank on the dates of 07/06/23 through 07/09/2023. Logging resumed on 7/10/2023 for the NOC shift. The AM shift logged showers for R1 on 07/06/2023 through 07/09/2023.

During staff interviews it was learned that there is a shower list that staff follows. Some residents are showered every day, but 2 – 3 times per week is more usual. Residents can elect to have their showers in the morning or at night. If R1 needed a second shower the NOC shift would shower them a second time. Staff interviews also revealed that the Point Click Care system was not updated with the daily shower requirement when R1 first moved in on 07/03/2023.

Expressions Director stated It depends on the resident’s care plan; they should be showered at least be 2-3 times a week unless their care plan requires more.

Executive Director stated It depends on the care plan; minimum average is twice a week standard.

It was determined that the facility did follow R1’s Health Evaluation/Assessment and Service Plan with an effective date of 7/10/2023 which requires daily showers and staff logged daily showers for R1 from 07/03/2023 through 07/09/2023. The facility needs to improve their logging of showers in the Point-Click-Care database. This allegation is unsubstantiated.

Continued on LIC9099-C

It was reported that no teeth brushing and denture care assistance was provided to a resident.

LPA reviewed Resident 1’s (R1) Health Evaluation/Assessment and Service Plan with an effective date of 7/10/2023 which says staff will provide physical assistance with personal grooming/hygiene tasks twice per day. This may include but is not limited to brushing teeth, combing hair, washing hands and face, shaving, applying deodorant, putting on glasses and hearing aids. The facility uses Point-Click-Care to log all ADL assistance provided to residents. LPA reviewed logs for the month of July 2023. R1 moved into the facility on 07/03/2023. There were days that the logs contain no data to prove or disprove that R1 received this assistance 4 times in the evening, 4 times in the morning and 3 days showed no logging for both the morning and evening.

During staff interviews it was learned that all residents, with the exception of two, require full assistance with oral hygiene. Staff provide this assistance every day as long as the residents will let them. 4 of 5 staff stated that care staff provide this assistance daily.

Expressions Director stated brushing teeth, brushing hair, and applying deodorant should be a daily task. Staff assist the residents. They are logged in our PCC (Point-Click-Care) as a task under hygiene and grooming.

Executive Director stated We try to encourage the residents every day, it depends on their mood, every resident is different. Sometimes some of them don’t want to have it done or don’t want to put their dentures back in but we encourage the best we can. All ADLS are encouraged and done in the manner the residents accept.

It was determined that the facility is assisting R1 and other residents with their hygiene needs. The facility needs to improve their logging of ADL’s in the Point-Click-Care database. This allegation is unsubstantiated.

Continued on LIC9099-C

It was reported that staff intermittently assist changing resident clothing, often times residents sleep in clothes the resident has worn all day and wearing them again the following day.

LPA reviewed Resident 1’s (R1) Health Evaluation/Assessment and Service Plan with an effective date of 7/10/2023 which says that staff are to provide physical assistance to R1 with dressing in seasonally appropriate clothing each morning and undressing and preparing for bed each evening. The facility uses Point-Click-Care to log all ADL assistance provided to residents. LPA reviewed logs for the month of July 2023. R1 moved into the facility on 07/03/2023, according to the provided logs R1 was assisted with changing their clothes in the morning and the evening with few exceptions. There were days that the logs contain no data to prove or disprove that R1 received this assistance 4 times in the evening, 4 times in the morning and 3 days showed no logging for both the morning and evening.

During staff interviews it was learned that staff assist residents daily with changing their clothes. If residents need to be changed more often due to their clothes becoming soiled staff will change them as needed. There are 2 or 3 residents that don’t like to change into pajamas. 1 of 5 staff stated when they come in the mornings the residents are still wearing the same clothes from the previous day.

Expressions Director stated Clothing is changed as needed if soiled, in the morning and at night for bed.

Executive Director stated Sometimes they like to change themselves it is once a day or as needed if they have an accident, everything is based on the care level. There are some that don’t feel they want to change because it is nighttime. It is more of a struggle due to sundowning. It is encouraged.

It was determined that R1 is consistently being assisted with changing their clothing twice per day, although the facility needs to improve their logging of ADL’s in the Point-Click-Care database. This allegation is unsubstantiated.

Continued on LIC9099-C

It was reported that there is a lack of janitorial services in the memory care unit.

LPA reviewed Resident 1’s (R1) evaluation and service plan which says that housekeepers are to clean R1’s apartment once weekly per schedule.

LPA reviewed the housekeeping schedule which reports that the memory care unit is cleaned on Wednesday and Sunday each week by housekeeping staff. On Wednesday the public restroom, dining room, kitchen, hallway, and entrance are cleaned. On Sunday the public restroom, dining room, hallway, entrance, and kitchen are cleaned. The memory care entrance, bathroom, and dining room are also included on a daily task schedule of cleaning which includes the following duties: Empty trash, dust, sanitize high touch areas, vacuum, sweep etc.

On 10/06/2023 LPA observed the carpet in the common areas and hallway of the memory care unit to be soiled. During another visit to the facility on 11/08/2023 LPA observed the carpet in the common areas and hallway of the memory care unit had been deep cleaned and was in satisfactory condition.

Expressions Director stated I know if it is needed the maintenance or house cleaner will do it. Other than that, I would say once every 3 months the carpet is cleaned by in house staff. A professional carpet cleaner is coming in to do Expressions this Friday. The floors are mopped multiple times each day, after each meal. Resident floors are mopped each week unless someone needs them cleaned before that.

Executive Director stated It has been a month since we cleaned the carpet. We are going to hire a professional carpet cleaner to do it now, we are waiting for a date. Staff mop floors as needed. Housekeepers mop floors once a day and the NOC shift mops them at night.

It was determined that the facility employs housekeeping staff that cleans each resident room weekly and common areas throughout the week, care staff mop floors after every meal, the carpet is shampooed by in house staff as needed and a professional carpet cleaner is employed as needed. This allegation is unsubstantiated.

Continued on LIC9099-C

It was reported that there are no activities for residents.

LPA reviewed activities calendar that is posted in Expressions. The calendar includes a mix of activities.

During staff interviews it was learned that the facility has an “activities lady” who comes to Expressions and does activities with the residents. They have conversations, play bingo and other games, and go for walks. Occasionally the Expressions residents are taken to assisted living to participate in activities.

Expressions Director stated For the most part, the activities director will do activities along with the residents and PCAs. Some things will change here and there. We will also take some residents up front for other activities, like karaoke and bowling if they want to.

Executive Director stated We have a schedule on the wall but sometimes it is confusing, we explain to families that we have a program plan in place but it does not always work so we have other things to engage the residents in.

It was determined that the facility has an activities calendar and adjusts the activities to suit the resident’s needs, interests, and abilities as needed. This allegation is unsubstantiated.

Facility does not have sufficient staff to meet the needs of the residents. UNSUBSTANTIATED

It was reported that the facility has a severe lack of staffing.

LPA reviewed memory care staffing schedules for the months of September and October 2023. The facility has four shifts in the memory care unit, 6:00 am – 2:00 pm, 2:00 pm – 10:00 pm, 4:00 pm – 10:00 pm, 10:00 pm – 6:00 am. All shifts had one Med Tech and one to two PCA’s on the schedule.

Continued on LIC9099-C

During the month of September 2023 PCA’s called out or did not show up for their shifts on the following days during the 6:00 am – 2:00 pm shift exclusively: 9/10, 9/18, 9/20, 9/26 PCA - No show. 9/21, 9/22 PCA – Personal. 9/27 PCA – Sick. On 9/17 two PCAs did not show up for their shifts which resulted in one PCA working back-to-back shifts to cover.

4 of 5 staff stated that staff assist the residents with showers, clothing changes, and activities of daily living. Staff did not provide any examples of care not being provided for the residents that would indicate that staffing is insufficient. Staff stated that in October 2023 there was one med tech and one care staff working on each shift in Expressions. As of November 2023, on each shift there is one med tech that works on both sides of the facility and two care staff on each shift in Expressions. Staff stated as long as everyone shows up for their shift they have enough staff. In December 2023 the facility increased their staffing in the memory care unit to include a total of 2 PCA’s and one med tech that serves the memory care unit exclusively per shift.

Expressions Director stated I have enough staff when they don’t call in with me back here also.

Executive Director stated there are two care staff, the med tech and the director on duty to provide care.

It was determined that the facility has sufficient staffing as no instances of care not being provided were proven as a result of the investigation. This allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED.

An exit interview was conducted. A copy of the report was provided to Executive Director Sonya Gonzales.