complaint·September 24, 2024

Report Continued on LIC 9099C... It was alleged that staff did not prevent covid outbreak. It was reported that there was a covid outbreak at the facility, but it was not disclosed to family members until after 12/07/2023. Records review and interviews conducted revealed the facility had their first resident test positive for covid on 12/02/2023. Following the first positive case, the facility began testing residents that reported not feeling well or displaying signs of weakness. In December 2023, the facility reported about forty (40) residents that had tested positive not including facility staff. Records review further revealed that facility had started reporting the positive cases to Ventura Public Health (VPH) on 12/03/2023. Personal Protection Equipment (PPE) carts were being placed in residents front doors and staff were monitoring residents and doing frequent checks. Interviews conducted with staff revealed that residents were encouraged and provided PPE when coming outside of their bedrooms and into common areas. Furthermore, although the facility had a covid outbreak, the facility was reporting to the proper agencies and family members as well as taking the necessary precautions to minimize the spreading. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff did not prevent covid outbreak”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy was issued. Report Continued from LIC 9099... It was alleged that staff neglected to check on resident resulting in multiple injuries and staff did not assist resident in a timely manner. It was reported that although Resident #1 (R1) is fairly independent, staff did not check on R1 for at least two (2) days. Additionally, R1 sustained bruises, sores, and scabs after falling due to R1 experiencing a fall. Furthermore, R1 called out for assistance but no one came. Information obtained during the course of the investigation revealed that R1 was admitted to the facility on 08/24/2023. Per R1’s physician report, dated 08/23/2024, it listed R1’s primary diagnosis as spinal stenosis and indicated R1 was able to follow instructions and communicate needs; however, required assistance with certain activities of daily living (ADL’s) such as bathing, dressing/grooming, and caring for toileting needs. Interviews conducted with staff revealed that all residents residing in assisted living have status checks conducted at least once per day. Staff stated that caregivers are assigned a “block” which is a list of residents that they are in charge of caring and making sure their needs are met for the duration of their shift. Staff interviews further revealed that residents that did not require assistance with ADL’s, had not had any recent falls or change in condition did not receive status checks, but were still checked on once a day. Additionally, staff stated that dining room staff usually report to caregivers if they did not see a particular resident during mealtimes. However, during December 2023, the facility had a covid outbreak which resulted staff to be understaffed, working double shifts, and they did not notice R1 had not been down at the dining room during meals. Additionally, per incident report submitted by the facility on 12/08/2023, it stated that on 12/06/2023, at approximately 2:00pm, staff was doing rounds and R1 was observed on the floor in their room, in pain and with a skin tear with discoloration to their left arm. Furthermore, during staff interviews, staff were unable to say or determine if R1 had been checked on a daily basis two (2) days prior to the unwitnessed fall incident. Based on the information obtained and reviewed, the allegation of “staff neglected to check on resident resulting in multiple injuries” in being deemed Substantiated at this time. It was also alleged that staff did not ensure resident’s call button was working. It was reported that R1 pushed their call button pendant, but the pendant did not work. Records review and interviews conducted revealed that R1’s pendant did not activate requesting assistance prior to being checked on by staff on 12/06/2023. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Interviews conducted with staff revealed that R1 was independent and did not require assistance with ADL’s or medication management. Staff stated that residents are given a pendant which they carry at all times; as well as having a call button / pull chord available in their bathrooms. Staff also reported that periodically pendants will go out and facility will either replace batteries or entire pendant. Furthermore, staff stated that R1 had reported pressing the call button calling for help after suffering the fall. Additional records review of Device Activity Report, dated 11/30/2023 to 12/07/2023, lists the resident name and room number in which a pendant was activated and the time it took staff to respond to the call. Per report dated 12/06/2023, it took approximately two (2) hours for facility staff to report that the pendant was functioning correctly as the pendant for R1 was not tested or activated until 3:59pm on 12/06/2023. According to incident report dated 12/06/2023, R1 was found on the floor at approximately 2:00pm. Based on the information obtained and reviewed, the allegation of “staff did not ensure resident’s call button was working” is being deemed Substantiated at this time. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.