Complaint Investigation Report

During today's visit there was one care staff w orking, and the Administrator was present. The Administrator was scheduled to complete their administrator duties and oversee care giving duties. LPA Martinez observed the Administrator making meals, providing care to residents, and cleaning. In addition, LPA observed care staff 1 (S1) providing care to the residents during today's visit. As a result, the Administrator was not conducting their administrator duties and one staff, S1, was attending to four residents. As a result, the facility did not have sufficient staff during today's visit to complete all facility work duties.

It was also learned during interviews that resident 1 (R1) requires two hands on assist with transfers and mobility. Additionally, R1's LIC 602 physician's report states R1 is bed bound and not able to transfer out of bed independently. However, facility staff reported R1 is able to ambulate with staff assistance when feeling well and not feeling weak. On today's visit, LPA Martinez observed R1 being transferred, which required two full hands on assist from the Administrator and S1. LPA Martinez observed very little assistance from R1 during the transfer. Moreover, during the transfer, the Administrator had to stop the transfer, and walk to the staff live in room, and ask staff 2 (S2) if they will be willing to work during the transfer. S2 was not scheduled to work, and does not have to assist with care giving although S2 assisted with R1's transfer, and the Administrator provide care and supervision to the other residents. It was also learned there is not always two care staff working at every shift during the weekends, which R1 requires two hands on assist leaving without their required care and supervision.

Due to this visit and LPA Martinez's observations, it was determined the facility does not have sufficient staff to meet the residents needs. In addition, it was determined the Administrator does not have the sufficient time to complete Administrator duties. Moreover, a case management was conducted on July 19, 2023 in regards to not maintaining resident records and conducting re-assessments.

As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D, and appeal rights were given to the facility.