Complaint Investigation Report

Regarding the allegation staff do not ensure that resident's dietary needs are met, it was reported that staff put food in front of the residents and leave them slumped over alone to eat. It was stated that R1 required assistance with eating. It was further reported that R1 has lost a significant amount of weight (approximately 30 to 50 lbs.) since being placed at the facility. Information obtained from interviews with facility staff advised that R1 does eat well balanced meals and can feed themselves. It was advised that R1 may need assistance with certain foods, but there are no documented plans regarding eating assistance in R1’s service plan. Interviews with additional residents indicated that there were no noted concerns with ensuring their dietary needs were met, they do not have any concerns regarding dietary needs being met to at this time. A review of the records confirmed R1 is able to eat with her hands but may require assistance if utensils are needed. Additional information obtained from observations revealed that R1 was able to eat without assistance. A review of the records did not corroborate that any significant amount of weight was lost the information obtained from a review of R1’s weight records confirmed a loss of six pounds from the time of admissions to discharge date on 05/21/2023.

Regarding the allegation the facility has insufficient staffing to meet the needs of residents in care, it was reported that staffing has been a consistent issue and the reason that most of R1’s needs do not get met. Information obtained from interviews with Administrator, Jennifer Gephart advised that the facility guidelines for staff meeting the needs of residents in care is to follow the resident’s plan of care upon admissions and to conduct an assessment. Interviews with additional staff indicated that R1 was receiving Hospice services and nurses were at the facility two to three times a week to attend to the needs of R1. A review of the records confirmed that R1 was receiving services through Cabrillo Hospice agency; narrative charting, nurses sign in sheets, and other documents were obtained. Interviews with additional staff indicated that the care staff are continuously training on personal rights care and supervision, and that staff are scheduled per each shirt to provide adequate care and supervision. Additionally, residents are encouraged to visit their primary physicians annually. Documents provided and reviewed on site to confirm this. Addition interview with administrator, Jennifer indicted that staff are continuously receiving training on personal rights, and the care and supervision of residents in care. Interviews with additional residents indicated that there are sufficient staff to meet their needs, and that there are all ways enough staff from the Med-tech to the nurses. The nurses are usually moving about there were no reported concerns. Information obtained from records reviewed included staff schedules and confirm adequate staff are scheduled per shift. No noted concerns document currently.