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32 | Staff members reported to LPA that during some of the AM shifts when an agency staff is working the overnight, they have witnessed multiple residents who's incontinence needs are not being met by staff. Staff reported witnessing several residents with soiled briefs who have been in the soiled undergarments for long periods of time and the briefs are cold full. Additionally, one family member corroborated the allegations and provided statements that during a visit, a family member had to use the restroom, call pendant was pushed and no response. Family member looked for staff to assist and could not locate any staff members to assist resulting in resident soiling themselves while awaiting for services.
In regards to allegation that there are not enough staff to meet resident needs, This allegation has been corroborated by four residents interviewed who all described delays in services or in some cases, no response to call light requests for services/assistance. LPA conducted interviews with caregivers and med techs on duty and all caregivers and med techs interviewed provided statements to LPA that there are not enough staff members scheduled each shift to meet all residents needs. All four caregivers and med techs interviewed identified typical staffing of four caregivers and two med techs on duty during each shift to care for the census at the time of 58 residents including memory care and assisted living, All staff interviewed provided statements that they are able to meet the scheduled needs of residents including, showering, medication administration, dressing and grooming residents. However, all caregivers and med techs interviewed identified responding to call lights for residents was a barrier at the current staffing level and there are times when staff members have been unable to assist residents in a timely manner due to not having enough staff members on duty to respond to requests for service or assistance while they are busy assisting other residents.
The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Neglect/Lack of Supervision is substantiated.
The following deficiency is cited per California Code of Regulations, TITLE 22.
Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
07/18/2024
Section Cited
CCR
87465(a)(1) | 1
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7 | Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by statements obtained from staff members, residents and family | 1
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7 | An updated written plan of correction will be submitted with an updated plan for responding to calls for assistance. |
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14 | members that facility has delays in response to calls for service which resulted in resident's needs not being met in a timely manner. | 8
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14 | |
Type A
07/18/2024
Section Cited
CCR
87411(a) | 1
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7 | Personnel Requirements - General
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of | 1
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7 | Administrator will contact management company for approval in hiring and scheduling additional staff members. Facility will provide written plan for responding to calls for service/assistance with greater oversight from RCC, Med Techs and nurse. |
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14 | personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by statements obtained from four staff members and four residents indicating there are not enough staff present to meet the needs of residents and respond time calls for assistance from residents witch poses an immediate health, safety or personal rights risk to residents in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
07/31/2024
Section Cited
CCR
87465(a)(1) | 1
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7 | Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by statements obtained from staff members, residents and family members that facility | 1
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7 | Facility staff will review and resubmit an incontinence care plan to ensure the needs of residents are met and all staff have the same knowledge of expectations. |
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14 | staff are not meeting resident's incontinence needs as evidenced by statements from AM caregivers that when agency staff are used overnight, residents are routinely wet, soiled and have appeared to be soiled for some time. A family member also reported staff failed to respond for assistance resulting in a family member soiling selves. | 8
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