Complaint Investigation Report

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.