On 5/28/22 between 1:36 pm and 2:17 pm, LPA interviewed staff. Staff #1 (S1) stated that “Staff help out wherever needed. Sometimes I can’t get to residents for one to five minutes.” S1 said that they work “12 hour shifts regularly during quarantine because it takes longer to deliver food to residents’ rooms than not to deliver.” S1 could not speak to the staffing levels in March 2021, however, S1 stated that “There have been only three servers since November 2021. One works breakfast and lunch, the other works lunch and dinner, and the other is a dining room service only.” Staff #2 (S2) says they are “short staffed” and that there is one server and one cook for 60-70 residents. “sometimes residents go home without a dessert.” S2 says that dining services staff call out for work “Five times per month. They don’t want to be here. They didn’t like the job or it was too overwhelming.” S2 explains that there is “often one caregiver on duty, over the radio and no one responds in a timely manner.” S2 further states that “other staff are helping in other departments who are not cross-trained.”

On 6/09/22 between 3:30 pm and 3:58 pm, LPA interviewed Staff #3 (S3) and Staff #4 (S4). S3 states that for the past two months, they have been working 6 days per week due to a need in the facility. S3 explains that they do not believe there is enough staff to accommodate residents. S3 says that on the 3:00 pm – 11:00 pm shift, there are two caregivers and one medication technician. S3 says that almost every day, one of the caregivers helps to serve dinner in the dining room, and that leaves one caregiver and one med-tech to cover dispensing medications and assisting residents. S3 says there is only one caregiver and one med-tech on the NOC shift, and the “most concerning” shift is the morning. S3 says there are two caregivers and one med-tech, and that the caregivers are very busy in the morning, assisting residents with showers. S3 says if anything else is needed, the med-tech must help out because the caregivers cannot leave residents during showering. S3 states that on some days, “showers are getting pushed back” because a caregiver is serving in the kitchen. S3 explains that caregivers and med-techs are also responsible for doing resident laundry. S4 stated S4 believes there are not enough staff to take care of all the residents. S4 explains that over the past two months, most days, the kitchen staff and wellness staff are short-staffed. S4 describes the ideal situation to be two to three caregivers on each shift who are solely there to assist residents with Activities of Daily Living (ADLs) and not required to help in the kitchen. S4 says that, on the 3:00 pm - 11:00 pm shift, there is one caregiver working in the dining room, and one caregiver and one med-tech “on the floor.” S4 reports that “about four times per month,” S4 has had to leave a resident to care for another.

Continued on 9099-C.

Exit interview conducted, civil penalty issued, and a copy of the report and Appeal Rights emailed to Administrator.

On 7/15/22 at 12:22 pm, LPA interviewed the former Wellness Director, Staff #6 (S6) who is an LVN. S6 says R1’s tests were only to be conducted by LVNs based on the nature of the tests. S6 says S6 assisted R1 with using the medical equipment and recording the results. S6 explains that R1’s doctor would send the order to the facility, and then S6 or another LVN would conduct the procedure for obtaining R1’s results using the medical equipment. S6 says they then recorded the results in R1’s charting and reported them to R1’s doctor. S6 says the doctor’s orders were sent to the facility weekly or as needed.

On 7/15/22 at 12:30 pm, LPA reviewed Narrative Charting for R1. Charting shows that facility staff recorded R1’s tests from 4/23/20 through 6/16/21. Staff #7 (S7) conducted the testing from 4/23/2020 through 1/26/2021. S7 conducted testing from 3/03/2021 through 6/16/2021. Charting shows a doctor’s order was received by the facility on 6/16/2021 and 8/05/2021. There were no notes indicating tests were taken after 6/16/2021.

On 7/15/22 at 12:40 pm, LPA spoke with Emily Villegas, Activities Director and former Executive Director, who states that the facility did not employ an LVN after 6/16/2021. She also states that it is the facility’s policy that med-techs are not allowed to conduct these types of tests.

Based on evidence obtained, the allegation “Staff not adequately trained,” is deemed Unsubstantiated at this time. LVNs assisted staff when the facility had an LVN. Med-techs were not assisting R1 with the testing. Therefore, staff who were conducting the testing were properly trained. However, the facility will be cited on a case management for not meeting R1’s needs since the resident had doctor’s orders after 6/16/21 and the facility did not provide assistance with these tests.

On the allegation, “Licensee is retaining a resident who requires a higher level of care,” the complainant’s concern was that the facility was allowing a resident to stay in the facility who has Dementia. The complainant was also concerned that the resident tried to “escape many times.” To investigate the allegation, LPA interviewed staff and witness, and reviewed records.

Continued on 9099-C.

On 6/17/22 at 4:40 pm, LPA spoke with Emily Villegas, Activities Director, former Executive Director. Ms. Villegas states that she does not remember if R2 received a re-appraisal. She does recall that R2 was upset that R2’s family was gone and left R2 there. She says R2 “threw stuff at the staff.” She explains that R2 thought they were only visiting for one week. Ms. Villegas says the family was called because R2 was not sleeping. Ms. Villegas believes the facility reached out to R2’s doctor, does not recall the outcome and was unable to provide documentation. She says that “the community was not a fit for R2.”

On 7/11/22 at 3:00 pm, LPA reviewed R2’s Admission Agreement which shows a move-in date of 6/25/21. R2’s physician report does not indicate a Dementia diagnosis, and R2’s refund form shows move-out date of 7/08/21.

Based on the evidence, the allegation “Licensee is retaining a resident who requires a higher level of care,” is deemed Unsubstantiated at this time. During interviews and records review, LPA learned that R2 was not diagnosed with Dementia and did not receive a re-appraisal during their time in the facility. However, the facility will be cited on a case management as the facility did not conduct a proper eviction.

On the allegation, “Inadequate food,” the complainant was concerned that the facility closed the kitchen early on 07/04/21 and that residents were served only sandwiches for dinner. Complainant also states that the food is of poor quality. To investigate the allegation, LPA interviewed residents and staff.

Continued on 9099-C.

On 5/28/22 at 1:36 pm, LPA interviewed S1. LPA asked S1 if there has ever been a time S1 has been without something needed to do their job. S1 says “no, sometimes there’s no cottage cheese which is a commonly asked for item, but I give a note to my supervisor, and it’s typically there within a day or two.”

Based on the evidence obtained, the allegation “Inadequate food,” is deemed Unsubstantiated at this time. Interviews indicate residents are satisfied with the quality and quantity of food provided in the facility.

Exit interview conducted and a copy of the report emailed to the Administrator.