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32 | the process quicker. This would eventually lead the staff person to raise their voice in further attempts to gain assistance from the resident.
It was learned that this type of treatment, verbal and physical, from the attending staff person left the residents feeling intimidated, stressed, and mistreated.
Based on interviews and the evidence that was gathered throughout the course of this investigation, it was learned that facility staff were required to acknowledge and respond to the call buttons once activated by the residents. It was learned that these types of call button activations ranged from requiring assistance in toileting, transferring in/out of bed, or flat out emergencies from falls or injuries. It was learned that facility staff were required to respond as quick as possible since it was unknown as to the reasons for the call button activations and facility staff persons were to never exceed a response time of more than 10 minutes.
It was learned that all call button activations were monitored and recorded upon initial activation up until the responding staff person was able to properly reset it in the residents room or personal pendant.
Based on a review of the facility call logs obtained for the months of August 2023, September 2023, and October 2023 it was learned that there were a total of 1,156 call button activations in the Memory Care unit of this facility. Of those 1,156 call button activations roughly 176 were responded to by facility staff but those responses were all in excess of 10 minutes or more. This equated to a 15 percent response time by facility staff that were in excess of 10 minutes or more.
It was learned that in that time span there also were documented response times that even exceeded the one hour mark as well.
As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met.
The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.
Appeal rights were printed and a copy was left with the facility designated Administrator at this time.
Exit Interview |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
11/23/2023
Section Cited
CCR
87468.1(a)(1) | 1
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7 | Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To be accorded dignity in their personal relationships with staff, residents, and other persons.
This facility was found to be deficient as | 1
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7 | The facility designated Administrator stated that a review of all facility caregivers training will be conducted. A statement of correction, along with updated facility staff training for no less than (1) hour in duration on the topic of Resident Dignity and Respect will be completed and submitted into CCL by the |
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14 | evidenced by staff persons handling residents roughly when attempting to assist them with their Activities of Daily Living (ADLs). This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care. | 8
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14 | due date. |
Type A
11/23/2023
Section Cited
CCR
87468.1(a)(3) | 1
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7 | Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions | 1
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7 | The facility designated Administrator stated that a review of all facility caregivers training will be conducted. A statement of correction, along with updated facility staff training for no less than (1) hour in duration on the topic of Residents Personal Rights will be completed and submitted into CCL by the due date. |
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14 | such as eating, sleeping, or elimination.
This facility was found to be deficient as evidenced by staff persons speaking inappropriately when attempting to assist residents with their Activities of Daily Living (ADLs). This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
11/23/2023
Section Cited
CCR
87411(d)(3) | 1
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7 | All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: | 1
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7 | The facility designated Administrator stated that a review of all facility caregivers training will be conducted. A statement of correction, along with updated facility staff training for no less than (1) hour in duration on the topic of Emergency Call Buttons and staff response will be completed and submitted into CCL by |
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14 | Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.
This facility was found to be deficient as evidenced by staff persons not responding in a timely manner when residents activated their call buttons, often times, exceeding more than 10 minutes which posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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14 | the due date. |
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