complaint·April 19, 2023

S1 indicated there was a PPE shortage. S2 was not working during this period but heard from coworkers that there was a PPE shortage. S3 said staff members were instructed to reuse gowns, but S3 used trash bags rather than reuse gowns. S5 and S6 said staff members were instructed to reuse gowns, but S5 and S6 went without gowns rather than reuse gowns. S4, S7, and S8 said they reused gowns. In interviews, administrator Revera said staff used disposable gowns more than once during this shortage, as follows: According to Revera, staff donned gowns to care for a COVID-positive resident, hung up the gown inside the resident’s room, left to take care of other tasks, then returned to the same room and used the same gown to care for the same COVID-positive resident. Revera said this took place during a three-to-four-hour period while she was out acquiring more gown supplies. The department has determined the following as it relates to the allegation that the facility is not following infection control procedures: Based on interviews with administrator Revera and with S3-S8, facility staff did not dispose of gowns as required during the recent COVID-19 outbreak. Therefore, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is being cited per 22 CCR Section 87470(b)(2)(B). An exit interview was held with Revera. A copy of this report and appeal rights were left with Revera.