It was reported that management took away one of the staff during the NOC shift so now there is only one staff for memory care and one staff for assisted living. Assisted living has several residents who are two person transfers and NOC staff are unable to assist them now.

LPA reviewed NOC staffing schedules for the dates of 03/01/2024 through 03/08/2024. The facility consistently had 3 staff on duty for the NOC shift with a combination of med techs and PCAs that provide care to both sides of the building. Med Techs also provide care to residents. This provides enough staffing to assist with two-person transfers during the NOC shift since most residents are sleeping during these hours.

Residents that were interviewed had no complaints about NOC staffing and said they had not had any problems but said the facility could use more staff.

Staff interviews revealed that the facility was staffing the NOC shift with one PCA on the assisted living side and one Med Tech/PCA on the memory care side. The facility recently increased NOC staffing to one Med Tech for both sides with a PCA on the memory care side and another PCA on the assisted living side.

Administrator stated On the NOC shift we have 1 med tech that goes between the two sides that serve as a med tech and a PCA, and 1 PCA for assisted living primarily. If Expressions needs help the MT/PCA goes over to help. The facility does adjust staffing to meet resident needs when required.

It was determined that current staffing levels are suitable for the NOC shift. This allegation is unsubstantiated.

Continued on LIC9099-C

It was reported that a lot of the calls from residents are left waiting and they have to wait at least 30 minutes for assistance.

Resident interviews revealed that sometimes it takes a long time and sometimes it doesn’t take long at all for staff to answer their call light.

Staff interviews revealed that it normally takes up to 2 minutes for staff to answer call lights.

Administrator stated The average is 7 minutes, but most get it in about 5 minutes.

This allegation is unsubstantiated.

Staff do not meet resident’s incontinence needs - UNSUBSTANTIATED

It was reported that Resident 1 (R1) got up and went to the bathroom by themself because the med tech was busy and did not make it to R1 in time.

LPA reviewed R1’s care plan which states that staff will provide physical assistance with toileting at routine intervals during day and evening when the resident is awake and as needed or requested by resident overnight.

Residents stated that sometimes their incontinence needs are met and sometimes not, they don’t think it’s a problem or don’t need that kind of help.

Staff unanimously stated that residents receive toileting assistance timely.

Administrator stated they are on the floor a lot and monitoring all shifts.

This allegation is unsubstantiated.

Continued on LIC9099-C

It was reported that staff are charting on the point-click-care system that Resident 3 (R3) is getting changed more often than they really are.

LPA reviewed R3’s ADL charting and found that the charting of toileting assistance for the dates of March 1 through 8 2024 in the Point-Click-Care system is inconsistent, some dates are filled in and some are not.

No staff had heard of or witnessed staff falsifying entries in the point-click-care system.

Administrator stated If someone is doing it (falsifying charting) and staff is aware and not reporting it that is concerning. We recently and are ongoing conducting staff training concerning the use of Point-Click-Care and the importance of documenting all care provided.

It was determined that staff are inconsistent with charting in Point-Click-Care, this does not constitute falsifying records. This allegation is unsubstantiated.

Staff do not ensure resident is bathed - UNSUBSTANTIATED

It was reported that residents are not getting showers because of the lack of staff. Resident 1 (R1) tells staff they did not get a shower. Resident 4 (R4) said that he did not get a shower.

LPA reviewed R1’s care plan which states Butte Hospice HH will provide bed bath/shower twice a week and will communicate to community when they are not available, and community PCA's will provide showers. LPA reviewed R4’s care plan which states that staff will provide physical assistance with showers per the shower schedule and R4 must perform bathing tasks as much as they are able with staff observation. Two staff are needed to assist R4 with ADL's for safety.

Residents stated they are receiving showers as required.

Staff interviews revealed that residents are receiving their showers unless they refuse. If a resident refuses the staff will check back at another time to see if they want to shower.

Administrator stated staff are able to provide showers to all residents but if a resident doesn’t want their shower or wants to shower at another time the schedule shifts. If there is an emergency, we ask if we can do it at another time. We alter the schedule as needed.

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.