Complaint·September 6, 2024

Based on records review, LPA Donato referred to PIN 21-38-ASC regarding masking. It states that All ASC (Adult Senior Care) residential facilities must strictly adhere to current CDPH Masking Guidance. During the time of the complaint the applicable California Department of Public Health (CDPH) Guideline, dated March 14, 2022, states that masks are required for all individuals in the following indoor settings, regardless of vaccination status. Surgical masks or higher-level respirators (e.g., N95s, KN95s, KF94s) with good fit are highly recommended, Long Term Care Settings & Adult and Senior Care Facilities . LPA Dolores was able to obtain a photo showing S2 leaving the room of R2 and wearing only mask. No other PPEs was worn or removed. LPA interviewed S5, and it was mentioned that there was an incident when a resident's family member saw S5 not wearing a mask. S5 had been eating or drinking something and forgot to put the mask on again. S5 knows masks are mandated in care facilities. Regarding the allegation of staff administered unsanitary medication to resident, RP stated that S7 dropped R1s medication on the floor next to R1s commode, picked it up, and placed it on the spoon to give to R1. During S7s interview, it was stated that the medication did not totally drop on the floor and dropped on the pants R1 was wearing. Another staff member (S6) confirmed that S7 did drop the resident’s medication and administered to the resident. In S6s interview of S7, confirmed to drop the medication, cleaned it, and gave it to R1. S6 states S7 put hand sanitizer prior to entering the room but did not perform hand hygiene inside the room prior to giving medication, then performed hand hygiene outside the room. LPA Dolores also interviewed other staff members. S1 mentioned that if a medication drops, they pick it up, report it to Health Services Director (HSD), and pop another one if it's from the bubble pack, give the clean medication to the resident, then inform the pharmacy for another tablet because they would be missing supply. They're not supposed to give it to the resident because it's dirty. Another staff member (S3) also stated that if meds spill, S3 picks it up and disposed the med in the waste bin. They'd administer new medication by popping a new one. They do not give the medication that dropped to the resident. If they pop another one, they'd inform the pharmacy, and they would send a new one. Therefore, based on interviews and records review and information collected, the above allegations are determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. A copy of this report and the Appeal Rights are provided. page 2 of 2 LPA has reminded RP that per HIPAA law, we are not able to disclose if a resident or staff have covid and that the facility is being monitored during this time. Regarding the allegation staff are not performing hand hygiene when assisting with medications, RP stated that staff member (S7) failing to sanitize her hands, or put on gloves, while administering medication R1. S2 entered the room and did not wash or sanitize his/her hands prior to touching the rim of R1s water cup. S7s fingers are touching the rim of the cup where R1 will be placing his/her lips as he/she drinks. S7 did not put on gloves either. LPA Dolores was able to interview S7 and it was stated that S7 would use hand sanitizer outside the room. S7 would enter the room and give the resident medication. LPA Dolores asked S7 if he/she would perform hand hygiene prior to administering the resident's medications and S7 states to already put on hand sanitizer outside the room. Based on records review, according to Title 22 regulation, 87470 Infection Control Requirements (a)(1)(A) Hand hygiene shall include hand washing with soap and water or using an alcohol based sanitizer or any other sanitizing method recommended by a medical professional, local health official, health department, or other research based medical authority. Based on interviews & records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. page 2 of 2 Based also on records review, according to PIN 20-13- ASC Notification To Families When A Person Tests Positive For Coronavirus Disease 2019 (Covid-19) , Upon confirmation that a person in care or facility staff member has tested positive for COVID-19, and either remains in the facility or is no longer in the facility, CCLD advises ASC licensees to provide immediate notice to families of all persons in care. The notice to all families shall not disclose any personally identifiable information or protected health information about the person who tested positive for COVID-19. Based on interviews and records review, the department has determined that that the allegation were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is reviewed and copy is provided. page 2 of 2