complaint·June 6, 2022

LPA observed guests arriving with masks on and temperatures being taken. Guests were at the front desk for an average of 30-60 seconds. LPA did not observe any guests take out their phone or wallet to show proof of vaccination or a negative COVID-19 test. LPA observed one child around age 7 or 8 arrive and no paperwork was shown or COVID-19 test administered. LPA viewed visitor logs from 3/19/22-3/24/22 and 5/6/22-5/8/22. Logs did not specify if the individual was vaccinated and showed proof, provided a negative COVID-19 test, or was tested at the facility. PIN 21-40-ASC dating 8/27/21 states that licensees must obtain and track documentation of vaccination or COVID-19 diagnostic test of visitors in order to visit indoors. Verification and record keeping shall take effect on 9/9/21 in accordance with the State Public Health Officer Order. The PIN states “Facilities must have a plan in place for tracking verified visitor vaccination status or documentation of a negative COVID-19 test. Documentation of the verification must be kept on file at the facility and made available upon request to CDSS, or to the local health jurisdiction for purposes of case investigation. Visitors for whom vaccine status is unknown or documentation is not provided, must be considered unvaccinated or incompletely vaccinated.” PIN 22-07-ASC updated 2/7/22 adds that unvaccinated visitors who visit consecutively are required to show a proof of a negative test every third day. Based on the information obtained, the allegation is deemed Substantiated at this time. A Technical Violation Notice Issued. Administrator agreed to redo the sign in sheet and track this data per PIN 21-40-ASC and PIN 22-07-ASC. On the allegation: Staff does not respond timely to resident calls for assistance. It was alleged that Resident 1 (R1) and their family pressed the pendant for help but no one came in a timely manner. LPA Olson reviewed call logs from 3/22/22-3/25/22. Records indicated R1 made a total of 7 calls. Pages go out to staff for around 5 minutes then automatically send a page out again up to 9 more times until the call is answered. Staff responded under 15 minutes to R1's call 3/7 times. Staff responded 15 minutes or longer 4/7 times, with one call not being responded to all. Records indicate on 3/22/22 at 5:40 PM R1's penant rang 9 times, and states “response required but not received as of 6:25p This alert was never responded to.” On 5/20/22, the administrator and staff interviewed stated the staff strive to respond to calls within 15 minutes or less. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility does not have adequate staff. It was alleged that a resident was found wandering the halls and it took time to find a staff to respond. It was alleged that Staff 1 (S1) told R1’s family member that she was working alone that day and had no help. Continued on 9099-C (2) LPA Olson interviewed staff who stated that usually there are 2 staff covering all residents. 4/5 care staff interviewed stated 2 staff was not enough to assist all residents. Staff stated residents with dementia require more attention and that there should be more staff to assist residents because there is a lot of work to do. In March 2022 the facility had 29/91 residents with dementia, 55/91 cannot leave the facility unassisted, 6/91 are on hospice, 12/91 Wander, and currently 1/94 residents need two person assistance (temporarily from 4/20/22- present), 10/94 need transfer assistance, 5/94 are bedridden, 43/94 are non-ambulatory, 16/94 are incontinent, and 11/94 require restroom assistance. 10/14 residents stated that there is not enough staff to assist residents and staff take a long time to respond when they need assistance. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Resident bathroom has a water leak. It was alleged that R1’s bathroom had a water leak and the ceiling had water pouring down and staff responded, “this happens all the time”. LPA Olson interviewed staff and residents that confirmed this happens when an upstairs resident’s toilet overflows or if the resident forgot to place their shower curtain the correct way and the water leaks down to the apartment below. Administrator stated “it is an old building, so it happens”. Facility Maintenance Director confirmed the water leaks through to the apartment below through the toilet if it is not sealed. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility is in disrepair. It was alleged that R1’s carpet tiles were dirty; the baseboards, shower head, facial tissue cover and fridge were covered with mold and hair; the toilet had a yellow ring and crusted urine and mold in the toilet seat bolts. LPA observed pictures from the reporting party and observed a yellow ring around the toilet as well as stains on the carpet and inside the fridge. LPA requested room checklist logs from the last 5 move-ins which show what was done prior to residents moving in. Facility could only produce 2/5 logs and calendar reminders/notes from housekeeping for the other 3 rooms. Three staff interviewed stated that all 5 rooms were cleaned and checked by sales, maintenance and housekeeping. One staff stated that they could have done better and the other two stated that management was informed of the condition of R1’s toilet, fridge, and floor prior to R1 moving in. Interviews revealed the toilet and fridge was replaced after R1 moved in. Based on the information obtained, the allegation is deemed Substantiated at this time. Exit interview, deficiencies cited on 9099-D, Technical Violation issued, report emailed, appeal rights emailed.