Complaint Investigation Report

The three (3) residents not interviewed were sleeping, at the hospital, or did not respond to LPA's questions. On 3/11/2025 from approximately 12:20 p.m. to 12:50 p.m., LPA conducted interviews with two (2) staff present and the assistant administrator. On 3/11/2025 from 12:50 p.m. to 1:45 LPA reviewed resident and staff records and obtained copies of residents’ Physician's Reports (LIC602A) and Appraisal / Needs and Services Plan (LIC625).

Allegation: Staff did not ensure facility had adequate staffing to meet resident's needs. Regarding the allegation, it was reported there is no overnight staff. To investigate the allegation LPA Rios conducted an initial visit on 3/11/2025. LPA's review of the facility's LIC500 revealed most shifts are from “7AM” to “7PM” with no overnight shift. The staff monthly schedule reveled two staff names on each day for this facility. The staff monthly schedule does not have which hours the staff member is covering. The assistant administrator admitted not verbatim that prior to three (3) weeks ago they did not have an overnight staff on schedule so relied on live-in staff to wake up and provide assistance when needed. Staff corroborated that there was no overnight staff assigned to provide care; however, staff would wake up if needed to assist residents with agitation, wandering, or incontinence needs. Staff interviews revealed that there is now one (1) awake staff member overnight to check on residents. LPA's review of facility's program under Basic Services states verbatim "Checks will be made on a regular basis, including night time. Patterns of incontinence will be discussed with physician. Night time, awake staff will be employed as necessary." Based on interviews and record review the allegation is deemed Substantiated.

Deficiency cited (refer to LIC9099-D). Exit interview conducted. Copy of report provided.