Complaint·September 25, 2025

Amended report 10/21/2025 to change finding from UNSUBSTANTIATED to UNFOUNDED All 7 out of 7 staff interviewed stated that the facility is following the facility’s infection control protocol, which includes providing staff with Personal Protective Equipment (PPE) such as gloves, masks and hand sanitizer. 6 Out of 7 staff state he/she is not aware of any viral outbreaks of illnesses at the facility. S7 states there was a viral outbreak of rashes at the facility in March 2025, and the facility did not provide gowns to staff. On 9/25/2025 LPA interviewed 2 additional Staff S8 and S9. S8 and S9 states the facility provides staff with PPE such as gloves and masks. LPA Tarin interviewed ADM. ADM states there were no viral outbreaks of rashes in March 2025. ADM stated in the event of a viral outbreak, the facility will follow the facility’s viral outbreak policy, and staff have access to PPE. LPA Tarin interviewed Residents R1 to R7. 3 Out of 7 residents state he/she has observed facility staff wearing PPE (gloves). 4 Out of 7 residents state he/she does not pay attention to whether staff are wearing gloves or masks. All 7 residents state he/she is not aware of any outbreaks of illnesses at the facility. LPA Tarin inspected 2 supply rooms located on the second and third floor of the facility. LPA Tarin observed 2 Out of 2 supply rooms with PPE supplies to include but not limited to gowns, masks, gloves, hand sanitizer, and shoe covers. LPA Tarin reviewed the facility viral outbreak policy dated May 2022, which states in the event of a viral outbreak, the facility shall follow the Department of Health’s procedures. The policy also states during virus seasons and during a viral outbreak, staff will be wearing PPE which includes a mask, gown, shoe covers and gloves. LPA Tarin reviewed Incident Reports for February to July 2025, and did not observe any reports of a viral outbreak at the facility. This agency has investigated the complaint alleging Staff are not following the universal precaution plan . We have found that the complaint was UNFOUNDED , meaning that the allegation was false, could not have happened and/or is without a reasonable basi s.