complaint·June 10, 2021

Historical supply records of PPE on-hand at the facility via COVID-19 Welfare Calls documented on LIC812 on 11/12/2020 and 02/08/2021 indicated a thirty (30) day + supply of PPE was inventoried at the facility on those dates for historical reference. LAP confirmed through interviews and email that a PPE supply audit is performed weekly and that supplies are ordered at least every two weeks through Medline. LPA observed facility PPE supply request completed by parent company, Compass Health, Inc. within hours, as an alternate PPE supply resource. LPA observed through photographic evidence of 6 boxes, containing 9000 pairs of gloves of assorted sizes, less than 12 hours from initial complaint investigation. LPA interviewed 13 of 15 staff (S1-S13), S1-S11 indicated through interviews that at no time in the past 12 months did the facility lack PPE or cleaning supplies. Interviews of staff and manager provided no evidence of shortage of PPE supplies in the past 12 months. LPA discovered no evidence to support the allegation of, “Facility is not following proper procedures to ensure sanitary conditions.” Therefore, the allegation is unsubstantiated, at this time. Exit interview, report emailed.