complaint·September 20, 2024

Allegation: Staff did not follow proper COVID-19 control protocols Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of staff (ED, S1) and reviewed facility’s spot COVID-19 line list report which showed COVID-19 positive residents and staff from 07/24/24 until 08/28/24. Review of the COVID-19 report showed that 4 staff tested positive for COVID-19 on 07/24,07/26, 7/29, 7/30 in Assisted Living and 2 residents in memory care on 08/02 and 08/05. All reported COVID-19 positive staff and residents were isolated until all symptoms were cleared and showed negative test results. On 09/05/24 at 3:30PM, LPA toured the facility with executive director (ED). LPA observed all on duty staff, visitors and some residents wearing face masks, hand sanitizers available for use in common areas. LPA observed facility clean, odor free and in good repair. LPA observed staff follows their COVID-19 infection control plan daily to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with ED as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed one central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. LPA observed COVID-19 signages posted throughout the facility to promote handwashing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff, visitors and residents Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged occurred. Therefore, the allegation that staff did not follow proper COVID-19 control protocols is unsubstantiated. Continued on next page, LIC 9099-C1 Allegation: Staff did not prevent resident from developing pressure injuries while in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of staff (ED) who stated that there are 2 memory care residents (R1, R2) diagnosed with Stage 2 pressure injuries. Review of R1’s needs & services plant dated 05/28/24 and physician’s report dated 06/24/24 show that staff conducts regular status checks on R1 4 times per shift, requires extensive multiple psychosocial interventions due to sundowning behaviors, requires total assist with bathing, dressing, toileting, ambulation to all meals and activities, medications and all transfers for safety. R1’s primary care physician (PCP) ordered home health care team to treat R1’s stage 2 wound on her coccyx twice a week. LPA also reviewed R2’s hospice records from 12/04/23 until current which showed R2’s stage 2 coccyx pressure injury is being treated by home health agency 3 times per week and that care was coordinated with staff with instructions to contact hospice agency immediately for any change in condition observed. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not prevent resident from developing pressure injuries while in care is unsubstantiated. Allegation: Staff did not properly care for resident’s pressure injuries Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of staff and reviewed resident’s (R1) call logs and incident reports. Review of memory care residents (R1, R2) medical records, assessments and hospice records show that staff provided proper wound care treatment for R1 and R2 as prescribed by their primary care physicians and home health care team. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not properly care for resident’s pressure injuries is unsubstantiated. Continued on next page, LIC 9099-C2 Allegation: Staff did not ensure that facility is free of pests Investigation Finding: Unsubstantiated During investigation, LPA reviewed pest control reports dated 11/14/23, 01/04/24, 01/07/24, 08/02/24 which showed that staff (ED) hired a professional extermination company to treat and fumigate the memory care unit for bed bug re-infestation which originated from one of resident’s recliner and wheelchair on 01/07/24. LPA also interviewed staff (ED, S1) who stated that one memory care resident loves to throw bird seed outside the memory care area close to the open field. Staff confirmed with LPA that 2 mice were observed in the kitchen and one resident's memory care bedroom area. LPA confirmed with staff (ED, S1) that the mice infestation was resolved by plugging the holes in the memory care kitchen and resident’s unit on July 30,2024. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure that facility is free of pests is unsubstantiated. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.