complaint·January 26, 2023

Facility staff did not properly handle potentially infectious material – SUBSTANTIATED It was reported that staff emptied a resident’s trash can that contained vomit without wearing gloves. LPA review of photograph of small wicker type trash can with a plastic liner that contained blue cups and napkins that contained what appears to be vomit. On 01/26/2023 LPA went into R1’s room and viewed the trash can in R1’s room which verifies this is the same trash can as in the original photograph. 6 of 6 staff interviewed stated they wear gloves when emptying trash cans and handling potentially infectious materials. Executive Director stated staff wear gloves when handling potentially infectious materials. It was determined that staff did not put on gloves before emptying a resident's trash can that contained vomit.This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to Executive Director John Crowley. Facility staff did not properly dispense medication to resident. – UNSUBSTANTIATED It was reported that a care staff picked up a pill from a surface in a resident’s room without gloves on and handed it to the resident. 4 of 6 staff stated they would not give the pill to the resident but would give the pill to the med tech so they could dispense a new pill. 1 of 6 staff stated they would not give the pill to the resident and would notify their supervisor. 1 of 6 staff stated they would put on a glove, place the pill in a med cup and hand it to the resident. 6 of 6 staff interviewed stated they wear gloves when handling medications. Executive Director stated staff wear gloves when dispensing or handling medications. They wouldn’t hand a pill; they would pop the blister pack into the cup and hand it to the resident wearing gloves. They would wash their hand before and after. There is not enough evidence to substantiate this incident. It was determined that the facility is properly dispensing medication to residents. This allegation is unsubstantiated. Facility staff are not following universal precautions. – UNSUBSTANTIATED It was reported that staff did not wash their hands when entering and exiting a resident room. During LPA tour of the facility on 01/26/2023 LPA observed staff practicing universal precautions. 6 of 6 staff stated they wash or disinfect their hands when entering and exiting a resident room. 5 of 6 staff stated they had been trained on universal precautions by a mix of videos, staff training sessions and job shadowing, 1 of 6 staff stated that their job duties did not require them to be trained on universal precautions. 4 of 6 staff stated they had never seen other staff not practicing universal precautions, 2 of 6 staff stated they had witnessed other staff not practicing universal precautions. Executive Director stated that staff absolutely follow universal precautions and the facility has completed monthly staff meetings and train on infection control and universal precautions during those staff meetings. It was determined that the facility is following universal precautions and conducts staff training on universal precautions. This allegation is unsubstantiated. Facility staff co-mingled residents during an outbreak at the facility. – UNSUBSTANTIATED LPA reviewed an incident report dated 11/15/2022 that reported the facility had a GI outbreak that started on 11/12/2022, 17 residents were symptomatic. As of 11/15/2022 the outbreak had abated. 4 of 6 staff stated during a recent Norovirus outbreak infected residents were not co-mingling with non-infected residents. 1 of 6 staff stated that infected residents were co-mingling with non-infected residents because by the time they were symptomatic they had already been in the community. 1 of 6 staff stated they did not know if infected residents were not co-mingling with non-infected residents. Executive Director stated We did our best, we have a couple of residents that were in shared rooms and we were moving the resident who was not infected out of the rooms to try to prevent them getting infected. This is memory care and there are residents who were infected who we could not keep in their rooms. It was determined that the facility practiced reasonable efforts to keep non-infected residents from being exposed to infected residents during the GI outbreak in a memory care unit. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to facility executive director John Crowley.