complaint·April 8, 2025

Based on review of facility’s infection control policy and procedures, it was determined that facility provided a linear approach to covid safety. LPA’s observation of facility revealed adequate amounts of personal protective equipment (PPE) in place as well as availability of hand sanitizers and isolation carts. As a result, there is a not a preponderance of evidence to conclude facility was not following necessary covid protocols, therefore, this allegation is UNSUBSTANTIATED. Allegation: No hot water in men’s bathroom in hallway. LPA conducted interviews and observations as noted above. Based on interviews conducted it was revealed that facility has consistently maintained hot water in men’s bathrooms and all other sections of facility since 1/1/2025 to current. Observations conducted revealed adequate hot water in men’s bathrooms and other sections throughout facility. As a result, there is not a preponderance of evidence to conclude facility has not maintained hot water availability in men's bathroom and other areas of facility, therefore, this allegation is UNSUBSTANTIATED. Allegation; Inadequate emergency food supply. LPA conducted interviews, observations, and record reviews as noted above. Based on interviews and observations, it was revealed that facility has consistently maintained adequate amount of food including two days of perishable and seven days of non-perishable items necessary for facility’s census. Observations conducted revealed facility has a designated section for emergency food which was stocked with adequate amounts. A review of facility’s menus revealed food items matched facility’s current stock of food on hand. As a result, there is not a preponderance of evidence to conclude facility did not maintain adequate emergency food supply, therefore this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights and LIC 811 provided.