complaint·April 19, 2022

Staff were alerted to R1’s appearance, yet it appeared that R1 had been sitting there for an undetermined amount of time. R1’s care plan revealed that R1 requires assistance with grooming and hygiene needs. Based on the information obtained during the course of the investigation, the allegation ‘facility staff failed to meet resident’s hygiene needs’ is Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted. A copy of the report, and appeal rights, were provided. Interviews revealed when R1 was temporarily relocated, R1’s clothing, furniture, and some personal items were placed in the temporary rooms. During that time, it appeared that some of R1’s items went missing. In addition, staff admitted that they believed that R1 was better suited for a different location in the facility due to their care needs. During this time, staff questioned whether R1 would be moved to a different room after the facility was cleared of the COVID-19 outbreak. However, additional discussion was had with R1’s responsible party and facility management regarding a suitable location for R1. At this time, R1 is currently residing in their original room. In addition, interviews confirmed that R1’s personal belongings have been located and returned to R1’s room. Based on the information obtained, there is insufficient evidence to support the claim that staff failed to safeguard resident’s personal belongings. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff neglected resident while in care It was alleged that Resident #2 (R2) is often found on the floor, and that staff were neglecting R2’s needs. Interviews confirmed that R2 oftentimes places themselves on the floor and that it was a reoccurring behavior for R2. Staff stated that they make attempts to assist R2 and move R2 to a more appropriate location, yet staff claim that R2 will place themselves back on the floor. The LPA reviewed R2’s care plans and identified that this behavior is notated on the care plan and that R2’s responsible party is aware. Staff recognize that although they clean and vacuum the facility that the flooring can appear unsanitary due to persons walking throughout the community. As such, staff claim that they want to ensure that R2’s personal rights are respected but also try to assist R2 to a more appropriate location as needed. Based on the information obtained during the course of the investigation, there is insufficient evidence to support the claim that staff neglected resident while in care. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Facility is not following proper protocol for COVID-19 It was alleged that R1 was hospitalized on 2/8/2022 and while in the hospital, was diagnosed with COVID-19. It was also noted that R1 was accompanied by facility staff and further alleged that because the staff was exposed to R1, the staff should have not returned to work. Interviews and records review revealed that R1 was accompanied to the hospital by Staff #1 (S1). Hospital discharge paperwork revealed that R1 tested positive for COVID-19, however, R1 was asymptomatic. Information obtained from an interview with S1 revealed that they were unaware that R1 was COVID-19 positive when they left the hospital. During that time, the facility was undergoing response-testing and S1 was tested for COVID-19. It was confirmed that S1 did not test positive for COVID-19 during the months of January-April 2022, S1 did not display any symptoms after going to the hospital with R1, and S1 was fully vaccinated at the time the incident occurred. Per the Provider Information Notice (PIN) 21-23 issued to facilities on 4/20/2021, “Fully vaccinated facility staff who are asymptomatic do not need to be restricted from work for 14 days following an exposure to COVID-19, per updated Centers for Disease Control and Prevention (CDC) guidance.” Based on the information obtained during the course of the investigation, there is insufficient evidence to support the claim that the facility did not follow proper protocol for COVID-19. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Facility is not following the visitation protocol It was alleged that the facility was not following the visitation protocol. Interviews revealed that the facility preferred have outdoor visitation as it poses a lower risk of transmission. However, staff stated that indoor visitation was allowed if the resident’s visitor was either vaccinated or had evidence of a negative COVID-19 test within one day of visitation for antigen tests, or within two days of visitation with a PCR test. Staff stated that if there were repeat visitors that preferred to have indoor visitation, they ensured that all visitors followed protocol as communicated by the local health department and Community Care Licensing. Staff mentioned that most visitors are comfortable with outdoor visitation but stated that indoor visitation was not denied. Staff stated that when the facility had a COVID-19 outbreak, they had separate outdoor visitation areas for residents whom resided in the Red Zone (positive residents), Yellow Zone (exposed residents, awaiting results), and Green Zone. Staff also shared that for those who were unable to leave the room or that fell under essential visitors, residents were allowed indoor visitation. Staff communicated that they understood the parameters for allowing indoor visitation, especially for visitors in critical condition. Staff denied claims that residents were denied visitation per protocol. Based on the information obtained during the course of the investigation, there is insufficient evidence to support the claim that the facility is not following the visitation protocol. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.