Complaint·February 11, 2025

The facilities infection control plan states that contact precautions are to instituted, staff training will be conducted and visitors will be notified. During the course of this investigation, records and statements, by staff and families, found that facility’s infection control measures were not implemented comprehensively at the unset of the outbreak (though improved during the course of this investigation). Additionally, during the time of the onset of the outbreak, a number of factors lead to occasional staffing shortages. Records and statements found that there were insufficient staff to meet the needs at times of residents. R4 is a 4 person assist for incontinence care when the use of hoyer lift was not yet utilized. AM staff were. At times, only an AM med tech and 2 staff, between 7-9 AM, leading to R4 having a delay in care while other residents were attended to and for other staff to arrive. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Administrator . Copy of this report and appeal rights provided.