Complaint·December 13, 2022

reviewed pertinent documents. The following was then determined: Regarding the allegation “Services not being provided in a timely manner:” Throughout the course of the investigation, LPA Dulek conducted interviews with staff and residents. Resident interview revealed that staff are doing a good job, are responsive to the residents’ needs, and occasionally medications are late, but none were reported to be greater than 30 minutes late. Medication review revealed medications were administered at regular intervals throughout the day, as prescribed. Residents did indicate that food was delivered later than ideal during the COVID outbreak at the facility, which coincides with the time frame of the complaint allegation. However, when the food was served, residents indicated facility staff would warm the food up for the residents and ensure each resident still received a warm meal of their choosing. Additionally, interview with Administrator revealed that the facility instituted a snack and hydration program to ensure all residents were provided snacks and water throughout the day. Interview revealed that the facility call light system was functional throughout the COVID lockdown and all staff, including agency staff carried their radios and ipods regularly. The facility’s policy outlines a 10-minute response time for all calls, however the facility staff acknowledges that this timeline can be difficult when multiple residents call at same time or when staff are busy meeting the needs of other residents. During the time the allegation was made, the facility was experiencing a significant COVID outbreak, which was initially reported on 12/28/2020 and resulted in continued daily communication and support from CCLD through 02/02/2021. Ventura County Public Health advised the facility to create COVID cohorts for COVID positive and COVID negative residents. Residents were asked to stay in their individual rooms, and care staff delivered all meals to resident rooms. Facility staff were required to wear full PPE to enter resident rooms and to change PPE prior to entering the next resident’s room, for the health and safety of all residents and staff. As a result, a care staff providing care to their regular 8 residents assigned also had to don and doff full PPE 8 times during each care run, adding an additional challenge to meet the facility’s 10-minute response time. Resident interview revealed that “they come on time” and with the exception of a few outliers, residents interviewed were happy with the timeline in which services are provided. Therefore, based on interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred; as thus, the allegation “services not being provided in a timely manner” is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C Regarding the allegation “Residents are being left soiled for an extended period of time:” LPA interviewed residents during the course of the investigation. All residents the LPA spoke with felt their incontinence needs were met, even during the time of the COVID outbreak. Staff interview revealed that incontinent residents are checked every 2 hours and as needed. Interview revealed agency staff who were employed at the time of the complaint were trained and were capable of changing residents regularly and as needed. Although the facility acknowledged that they were experiencing staffing shortages due to the COVID-19 outbreak at the facility, they utilized staffing agencies, instituted a 12-hour shift rather than regular 8-hour shifts, and all staff were trained and utilized on the floor for direct care, including management staff. Another strategy the facility employed was utilizing as many staff as possible as care staff and asking the staff to complete all ADL tasks at a time when entering a resident’s room, due to the need for full PPE. For example, staff would deliver the resident’s food, assist with dressing, grooming, and incontinent needs all during one trip to the resident’s room, rather than making multiple trips for each individual task. Residents interviewed felt their incontinence needs were met and staff interviewed indicated they did not hear any complaints from residents regarding incontinence care. Based on interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation, therefore, the allegation “residents are being left soiled for an extended period of time” is deemed UNSUBSTANTIATED at this time. No citations related to this complaint were issued. Exit interview conducted. A copy of the report was provided via email.