complaint·February 26, 2026

Allegation: Facility does not have hot water. It is alleged that the facility did not provide hot water at resident bathrooms and common area sinks, including the bathroom near the kitchen and the dining room sink, for several days. Staff consistently reported there was no complete loss of hot water at the facility. Staff reported temporary issues involving low water pressure and a required water shutoff on 2/11/2026 after approximately 8:00 p.m. to complete plumbing repairs, including replacement of a water pressure regulator and repair of a piping leak. Staff stated hot water remained available outside of the repair period, although pressure was reduced at times. Staff reported residents were notified of the temporary disruptions. Plumbing services were contacted and repairs were completed, as reflected in work orders and invoices reviewed by LPA dated 2/11/2026 and 2/17/2026. R1 reported experiencing a lack of hot water for several days, including the date of the investigation visit. R1 stated they were not notified of any water shutoffs and reported maintaining a log documenting days without hot water. During resident interviews R2–R7, Residents provided varied statements. Several residents denied experiencing issues with hot water or reported having continuous access to hot water. At the time of the visit, all residents interviewed confirmed that hot water was available. LPA verified hot water was accessible in resident rooms and common areas during the visit. During Witness One (W1) interview, W1 confirmed plumbing services were rendered at the facility and that repairs were conducted on 02/11/26 after approximately 8:00 p.m., once the kitchen was closed, in order to minimize disruption to residents in care. W1 stated that certain repairs may take several hours to complete and explained that during active plumbing repairs, water service must be shut off. W1 further stated that if a resident attempted to use water during the repair period, water may not have been available. W1 explained that for certain repairs, such as a piping rupture, initial work may be completed during daytime hours to patch the pipe, with follow-up visits occurring in the evening to complete full repairs, which require shutting off the water supply. During the facility walk through, LPA tested the dining area sink and observed hot water available. LPA documented the observation with a photograph and observed posted hand-washing guidelines. LPA toured the kitchen and observed hot water available, hand-washing signage posted throughout the kitchen, and hand sanitizer present at workstations. (continued on 9099C) LPA received Unusual Incident Reports related to both the pipe leak and the hot water pressure issue, which included notification of a temporary and slight water shutoff. LPA observed the bathroom near the dining area to be clean, with hot water accessible. LPA inspected a total of eleven (11) resident bedrooms, including R1’s room, and observed hot water available in each room, meeting regulatory temperature requirements between 105°F and 120°F. Some faucets required additional time to reach the required temperature; however, hot water was available. LPA reviewed work orders and invoices related to the water pressure regulator replacement and the piping leak repair, which reflected that the issues were addressed and corrected. Allegation: Staff did not observe personal hygiene and sanitation practices to maintain infection control. It is alleged that staff did not wash their hands using warm water and soap while performing duties. During resident R1 interview, R1 alleged that dining room staff (servers) did not consistently practice proper hand hygiene. R1 reported observing servers assist residents with walkers and then proceed to other duties without washing their hands. R1 further alleged that staff did not wash their hands using warm water and soap and stated that on the date observed, hot water was not available. During staff interviews, staff consistently reported they follow proper hand hygiene practices. Staff stated they wash their hands with soap and water, use gloves as required, and follow posted hand-washing guidelines. Kitchen and dining staff reported hands are typically washed in the kitchen area, where hand-washing supplies and signage are posted. Staff reported that hand hygiene is routinely practiced during resident care. During the facility walkthrough, LPA observed sufficient supplies of hand soap and hand sanitizer available in the kitchen, dining area, and common areas. Based on the investigation conducted, which included interviews with staff, witness, and residents, as well as a review of relevant records, there was insufficient evidence to support the reported allegations. 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 . Exit interview was held, and a copy of this report was provided.