Complaint·May 6, 2024

On the allegation: Facility staff did not follow infection control procedures. It was alleged that during a COVID-19 outbreak, the facility’s cleaning supplies were locked up and inaccessible to staff. Therefore staff could not properly disinfect and following infection control procedures. Staff interviewed stated over Labor Day weekend, they were unable to access the cleaning supplies in the laundry room and therefore could not properly disinfect. Based on the evidence obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility did not provide residents basic supplies. It was alleged that the key to the laundry room was lost, and therefore staff did not have access to cleaning supplies, laundry facilities, towels or toilet paper. Multiple staff interviewed confirmed over Labor Day weekend, they did not have the key to the laundry room and could not access it. Staff confirmed they did not have access to towels, toiletries, toilet paper, tissues, or cleaning supplies. Staff stated they reported the lack of access to the Memory Care Director when they came on shift and realized the keys were missing. Staff confirmed a visitor brought toilet paper in for the facility. Visitor interviewed stated they brought in one roll of toilet paper for a resident on 9/2/23 and on 9/3/23 brought in a 48-roll pack of toilet paper for all residents. LPA reviewed a locksmith invoice dated 9/5/23. The invoice indicates a mobile locksmith call and new knobset was installed. Based on the evidence obtained, the allegation is deemed Substantiated at this time. On the allegations: Facility is not clean and Facility is in disrepair. It was alleged that a resident’s toilet was clogged for at least four days, and a resident’s toilet was dirty for at least a week with feces present on it. Visitors were interviewed, who stated R1’s toilet was clogged with feces over Labor Day weekend. Visitors stated the facility was unable to get a plumber to fix it until the Tuesday after the holiday. Staff interviewed confirmed the facility had plumbing issues prior to Labor Day weekend and a plumber had already visited the facility. The plumber fixed the plumbing in Room 1, but then later multiple other rooms backed up. Staff stated the plumber came back two to three times to the facility to fix it. Staff stated the facility has a chronic ongoing issue with the plumbing, possibly due to residents putting items or wipes down the toilets. Continued on 9099-C LPA reviewed a plumbing invoice dated Thursday 8/31/23 to fix Room 25, which corroborates that a plumber started addressing the issues prior to Labor Day weekend. Visitors interviewed indicated one resident’s room has a broken heater, and the ceiling has water damage due to a previous leak. LPA during walk thru on 5/6/24 observed water damage to ceiling is still present and it was requested that proof of heater functioning be provided. Staff stated the laundry room wasn’t locking for approximately one month, an d the medication room door does not securely lock. During the tour, LPA Kontilis observed the medication room handle, and staff demonstrated the door does not stay locked unless the handle is held up when closing it. During the tour, LPA Kontilis also observed a broken doorknob in Room 4. The door handle inside the room fell off when pulling the door closed, which could pose a danger to residents. During walk thru on 5/6/24 LPA found that multiple keys have been obtained and other work around for possible lock outs have been planned as well as there was no loose door handles noted at this time. Based on the evidence obtained, the allegation is deemed Substantiated at this time. Exit interview conducted, copy of report given.