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32 | S3 says that residents have higher needs and there are “four heavy wetters who need changing every hour, others who need changing every two hours, and two residents who need a two-person assist.” S4 reports that there are two caregivers and one concierge per neighborhood and that “one to two times per month, we need more concierge in events.” S4 further explains that “At times, it is hectic, and we need more people.” S5 says there are “16-18 residents, 3 PCAs, and 1 concierge.” S5 explains that “3-4 staff work double shifts almost every day.” S6 says they work double shifts 2-3 times each week and that “lately it’s been worse.” S6 describes the situation, saying “new people quit quickly.” S7 explains that there are “a lot of people working double shifts since January 2021, at least 2-3 staff working double shifts daily.”
On 9/17/21 at 3:07 pm, LPA interviewed Witness #1 (W1). W1 says that they had to “train the staff on mom’s needs, i.e. changing her (diaper) regularly, feeding her properly and feeding her regularly, turning her, showering her.” W1 stated that they “were not taking care of her due to a shortage in staff, new staff not being trained fully, and too few caregivers to get the job done.”
On 7/21/22 between 2:15 pm and 2:59 pm, LPA interviewed Staff #8 (S8) and Staff # (S9). S8 says regarding incontinent needs that “It’s happened (residents not getting changed) about three times in the past 10 years.” S9 says they observed “Two staff who did not attend to residents’ toileting needs for more 30 minutes.” S9 further explains that “Staff are tired from working double shifts, and sometimes they don’t tend to residents’ needs.”
On 7/22/22 between 9:55 am and 10:45 am, LPA interviewed Staff #10 (S10) and Staff #11 (S11). S10 reports that it is discussed with staff in crossover meetings. S10 says they do not know of any staff who had problems with changing residents’ diapers. S11 says “It happens sometimes. Staff may be helping other residents,” and S11 says they do not recall any staff in particular who did this.
On 8/11/22 at 1:22 pm, LPA spoke with Witness #2 (W2). W2 says that their mother is “Typically is taken care of, however, her teeth bothered her, and staff don’t really assist with brushing her teeth.” W2 explains “Her hair looks terrible. Staff does a great job considering I don’t think they have enough people.”
Based on the evidence obtained, the allegation “Staff not meeting residents care needs” is deemed Substantiated at this time. Interviews reveal that there was a staffing shortage, and residents were not being cared for in a timely manner. Deficiency cited on 9099-D.
Exit interview conducted, deficiency cited, and a copy of the report and appeal rights emailed to the administrator.
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