complaint·August 28, 2025

Regarding the allegation: 1.) Staff do not ensure infection control guidelines are being followed. It was alleged that during a potential Coronavirus disease (COVID-19) outbreak at the facility that the facility did not have any PPE for staff to wear when entering the residents rooms. Interview with the ED revealed that in August 2024, there were two (2) COVID-19 positive cases, one (1) staff and one (1) resident. The ED explained that the facility has sufficient amount of Personal Protection Equipment (PPE) such as gloves, mask and gowns. The ED explained that when a resident test positive for COVID-19, staff place a three (3) tier storage drawer filled with PPE outside the residents room along with a trash can to dispose of the used PPE. During the physical plant tours, the LPA observed sufficient amount of PPE at the facility. The Wellness Director, Gloria Morales explained that supplies, including PPE are ordered on a monthly basis. Additionally, the Wellness Director explained that staff get trained on infection control policies and procedures annually. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. 2.) Staff do not ensure care needs of resident are being met. It was alleged that Resident #1 (R1’s) needs were not being met as staff would bring R1’s food tray when R1 was isolating and would leave it outside of R1’s door in which R1 was not able to reach down to the floor for the food. It was also alleged that the facility was not restocking adult diapers in a timely manner for R1. Interview conducted with R1 did not reveal any concerns regarding staff and R1’s care. Staff interviewed denied the allegations. Staff interviewed revealed that if residents require food trays to be brought to them, staff bring the food inside the rooms and next to the residents. The Wellness Director explained that R1’s family supplies adult briefs for R1 and that the facility provides extra adult briefs for R1 as needed. The LPA observed the facility to have additional incontinent supplies such as briefs for resident use. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted with Wellness Director. A copy of the report was provided.