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13 | Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the allegations. LPA met with Administrator Mike O'Neil at 10:50 AM and explained the purpose of the visit.
LPA Rosales conducted the initial Complaint visit on 04/30/2021 at 1:56PM, virtually toured the facility, conducted telephonic interview with Administrator at 2:23pm and requested copies of pertinent documents, interviewed staff at 10:39 AM, 12:07 PM. LPA Rosales conducted a subsequent complaint visit on 06/15/2021 at 10:04 AM, toured facility and interviewed staff at 11:45 AM, 12:09 PM, 1:01 PM, 2:06 PM and interviewed resident at 1:21 PM. During the investigation LPA Rosales conducted staff interviews on 05/24/2021 at 11:48 AM, 12:05 PM, 12:14 PM, 06/04/2021 at 2:21 PM, 06/07/2021 at 4:14 pm, and 06/18/2021 9:22 AM. LPA Rosales interviewed resident on 10/05/2021 at 3:08 PM and Witness on 05/18/2021 at 1:25 PM. LPA Ascencio interviewed staff on 05/05/2022 at 2:50 PM. LPA De Leon interviewed staff on 04/16/2023 at 11:45 AM and 11:59 AM. LPA De Leon is delivering the final findings of the complaint investigation on 04/16/2023.
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| Substantiated | Estimated Days of Completion: |
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32 | On the allegation: Insufficient staffing. LPA’s interviewed staff which revealed one staff stated the facility was very short-staffed during April of 2021. One staff stated they were left alone with out help on a shift and had a resident refusing medication with out-of-control behaviors staff had to call family and paramedics they turned in their two weeks’ notice after that incident. One staff stated one night a resident fell and staff had to leave one building with no staff to go over to help another staff in the other building so the residents were left alone. One staff stated there is one Medication Technician on NOC shift for 3 buildings and only 1 staff in each building. One staff stated often there is not enough staffing. A resident interview stated at times they do not get showered sometimes for 4-5 days even when they have asked to be showered, the NOC shift only has one staff, and they were not answering the pendant press and the resident went out the door and could not find anyone on shift. LPA De Leon reviewed the facility records for staff schedules during the month of April 2021. The facility schedule is for two buildings the Maricopa and the Topa Topa buildings are staffed with 1 AM Lead staff is scheduled, and 3 Guides staff are scheduled, on the PM 1 Lead is scheduled and 3 guides are scheduled, the NOC shift has 1 lead and 1 Guide is scheduled, the lead guides scheduled are the lead for both buildings and the guides are in each building. On 80 occasions during the April 1, 2021, to May 1, 2021, schedule, shifts were open, staff called out, staff wasn’t scheduled, AM, PM, and NOC staffed either worked later, came in earlier, or covered additional shifts, and LVN covered some shifts. On the NOC shift schedule for 04/11/2021 and 04/12/2021 1 staff was scheduled as lead for 2 buildings and only 1 staff was scheduled in the Topa Topa building, no guide was scheduled in the Maricopa building so the lead would not have been able to leave the Maricopa building on those nights to help the guide in the Topa Topa building without leaving the Maricopa building without staff. Several staff stated notes were put into the system by the NOC shift around the date of 04/12/2023 shift that in the early am resident (R1) fell or rolled out of bed and staff were instructed to put him back in bed and LVN would check on resident. On those dated the facility was short staffed based on the schedules. Based on the evidence this allegation is deemed Substantiated at this time. |
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32 | LPA De Leon reviewed those staff notes and the facility was not able to produce a note entry for R1’s slips out of bed or fall on the NOC shift by S12 during 04/12/2021 – 04/13/2021. Based on the evidence this allegation is deemed Substantiated at this time.
On the allegation: Staff did not seek timely medical attention for resident. LPA’s Rosales, Ascensio and De Leon interviewed a total of 13 staff during the investigation. LPA Rosales interview with Administrator stated that R1 had an unusual condition. R1 was experiencing pain. Administrator stated that at one-point R1 rolled out of bed and immediately staff sent R1 out for Xray, R1 had verbalized pain in R1’s hip area, x-rays were all fine, the resident then experienced a change in condition. S5 interview revealed R1 had 7 weeks previous to an incident with R1 on 05/19/2021 R1 had fallen and had a fracture on R1’s hip joint which is why R1 needed to stay in bed or in a chair, R1’s doctor said R1 didn’t need surgery. S5 said Staff have been using a lift because R1 cannot weight bare. S5 admits S5 did not call R1’s family to let them know about the change in condition. Staff interviews revealed R1 had a fall on the NOC Shift at some time during the early am of 04/13/2021. Staff Notes were written in the system by S12, and the entry could not be produced by the Administrator. R1 was not sent out after the slip or fall out of bed on 04/13/2021 early am, notes produced by the facility showed entry on R1 by Staff on 04/13/2021 at 1:40 PM very week today, had to use another resident’s wheelchair to transfer, right side of face was swollen and has a bruise on his right elbow. Had to have assistance today for both meals with feeding, in bed laying down. A later entry on R1 by another staff dated 04/13/2021 10:22 PM, R1 had difficulty with standing, needed a two person assist, complained of pain when moving, ate 100% of dinner, wanted to get up and walk, took a few steps with difficulty unable to take a step with left leg, two guides assisted with R1 wanting to walk, no complaints of pain at time. Another note entry for R1 on 04/14/2021 at 3:33 PM states Tomorrow I will be taking resident for X-ray of his back and left hip, W1 reports R1 has had problems with R1’s back in the past. R1’s doctor wants to check and make sure then will go from there. |
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32 | On 04/15/2021 at 1:14pm R1 has an entry stating Took Resident this morning for X-Rays of his left hip and lower back has metal in it from past surgeries, vertebra infused together waiting to hear from R1’s doctor. Entries go on from there dated 04/15/2021 stating R1 was very lethargic, dead weight, was in the wheelchair, very weak, was unable to get up on own. On 04/16/2021 at 1:37 PM other notes on R1 stating very week, very sluggish, put back in bed, took 3 to transfer, sent out to the ER after lunch has not returned. R1 returned to the facility on 04/16/2021 with UTI and prostate infection. R1’s slips out of bed, fall happened on 04/13/2023 around 5 AM, R1 was not sent out for X-Ray until the morning of 04/15/2021 and R1 was not sent out to the ER until 04/16/2021 after lunch. Based on the evidence this allegation is deemed Substantiated at this time.
Exit interview conducted, Deficiencies cited, Copy of Report and Appeal Rights printed for Administrator. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
04/19/2023
Section Cited
CCR
87468.1(a)(8) | 1
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7 | (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(8)To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs, This requirement was not met as evidenced by: | 1
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7 | Administrator agreed to hold a training on Personal rights of residents, regulation 87468.1 and 87468.2, train on the facility procedures on |
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14 | Based on Interview/records review the licensee did not comply with the regulation above Staff did not inform R1’s Family of a fall which poses an immediate personal rights risk to residents in care. | 8
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14 | reporting when a resident has an incident, provide proof of trainings to CCL. |
Type A
04/19/2023
Section Cited
CCR
87465(g) | 1
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7 | (g)The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by: | 1
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7 | Administrator agreed to train staff on regulation 87465, facilities fall prevention, policy and procedures, when to notify 911 and how to follow up on resident |
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14 | Based on interviews/record review the licensee did not comply with the regulation above R1 had a slip/fall incident on 04/13/2021 and the facility did not seek medical attention until 04/15/21 and 4/!6/21 which poses an immediate health and safety risk to residents in care. | 8
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14 | care after discharge. Send proof of training for all care staff and an up-to-date LIC 500 Personnel Roster to CCL. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
04/24/2023
Section Cited
CCR
87411(a) | 1
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7 | a)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 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: | 1
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7 | Administrator agreed to maintain sufficient staffing to meet all the resident in care needs and provide a current schedule of each building with the staff names and |
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14 | Based on interviews/record reviews the licensee did not comply with the regulation above. Staff were insufficient on some shifts which poses a potential health, safety, and personal rights risk to residents in care. | 8
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14 | times on shifts, provide a list of back up staffing or agencies that can come in to cover open/vacant shifts, provide an up-to-date LIC 500 and read, review, and have an understanding of regulation 87411. |
Type B
04/24/2023
Section Cited
CCR
87506(b)(13) | 1
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7 | (b)Each resident’s record shall contain at least the following information:(13)Continuing record of any illness, injury, or medical or dental care, when it impacts the residents ability to function or needed services. This requirement was not met as evidence by: | 1
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7 | Administrator agreed to read/review regulation 87506 and train staff responsible for keeping record of residents on facility policy and procedures to secure records. Provide training records for staff responsible and facility policy and procedure to CCL. |
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14 | Based on interview/record review the licensee did not comply with the regulation above records for resident were not produced for review by licensing upon request which poses a potential Health, Safety or Personal Rights risk to residents in care. | 8
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14 | records. Provide training records for staff responsible and facility policy and procedure to CCL. |