complaint·September 7, 2023

The investigation revealed the following: Allegation: Facility did not follow mask use guidelines. It is alleged that at the time the order was given to wear masks at all times residents were not prompted to do so, only time they were was when taking a Covid test. Review of training logs showed ongoing training of Covid guidelines for mask use. During interviews with Staff 5 out of 5 Staff stated that during the Covid period staff tried their best efforts to mandate the masking requirements, although sometimes residents would not wear their masks and give some push back, Staff would continuously remind them to put on their mask and wear them properly at all times, after the reminders the residents would cooperate. During interviews with residents 8 out of 8 residents denied the above allegation and stated that they were constantly encouraged and reminded to wear masks and if a resident wasn't wearing a mask staff would ask them to put one on or provide them with a mask and have them put it on. Allegation: Facility staff did not have adequate PPE. It is alleged that PPE supplies was not readily available until after a quarantine was issued. LPA observed the PPE supply during todays visit, there was a storage room that had cabinets filled with masks, gowns, shield, gloves, Lysol and hand sanitizer. LPA interviewed Staff and 5 out of 5 Staff all stated that the facility has maintained sufficient PPE supplies since the start of the pandemic and that supplies were provided regularly by the city, licensing and purchased by facility as well. Staff also stated that there were PPE supply stations throughout the facility so that it was readily available when needed, and would be refilled when running low. During interviews with Residents 8 out of 8 residents interviewed denied the above allegation. Residents interviewed stated that they never had issues with getting any masks or sanitizer during that time or now, they also stated that masks were always readily available and if they didn't have a mask or other PPE supplies they could ask for some at the front desk and supplies were provided right away. Allegation: Facility is not cleaning and disinfecting as needed to prevent spread of infection. It is alleged that there is insufficient deep cleaning and disinfection done at the facility. LPA interviewed 5 Staff and 5 out of 5 Staff stated that the cleaning was increased once the pandemic hit, disinfection and cleaning was done hourly and even in-between as needed, and staff are still practicing the disinfection procedures. Review of training logs showed ongoing training of Covid guidelines for disinfection and (Continued on 9099-C) cleaning. LPA interviewed 8 Residents and 8 out of 8 denied the above allegation and stated that they noticed Staffs increase of cleaning and disinfecting. Residents interviewed stated they feel that staff was cleaning all the time and all throughout the day. Based on statements and interviews conducted with staff and residents, and review of training and Infection Control Plan, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Administrator Maria Jacobo.