Complaint Investigation Report

The investigation revealed the following:

I n regards to the allegation: "Licensee does not ensure an adequate supply of PPE is provided for staff." It is alleged that facility has inadequate supply of PPE for staff to use while providing care to the residen t , and prior to entering the resident rooms and no PPE for staff to use the first 2 days. (5) of (6) staff interviewed stated that PPE supplies are adequate and available for staff to use. Some staff indicated that they conduct weekly audits of their supplies such as gloves, masks, med cups, hand sanitizers and replenish them as needed. S2 stated that their PPE supplies are ordered through Amazon which offers expedited delivery, often with same - day delivery. (1) of (6) staff interviewed stated that although they don't know where to get the PPE supplies, they get it from their supervisor if they ask . (10) of (10) residents interviewed denied the allegation and stated that the facility always have masks or sanitizers available. During the visit on 12/23/2025, LPA observed sufficient stocks of PPE supplies in cabinets in the med room, storage room and in the office of the House Services Director . Therefore there was insufficient evidence to corroborate with this allegation.

In regards to the allegation: "Licensee did not ensure infection control measures were properly implemented." It is alleged that on 12/16/2025, staff learned that R1-R3 have different kinds of infections and found out of their infections during shift change since the administrator did not inform them of this . Staff interviewed stated that the hospice nurse for R1 visited R1 on 12/15/2025 and ordered a new antibiotic medicine because there was a high probability that R1's illness was contagious. However, some staff stated that they still followed the infection control guidelines, although there was no confirmed diagnosis that R1 has an infectious disease. Some staff stated that they were using gloves and masks when providing care to R1. S6 stated that PPE supplies such as gowns, masks, and gloves were placed outside the residents’ rooms on the same day they learned about the infection. On the evening of 12/16/2025, S6 also stated that they texted the care team with the preventative measures and instructions . Documents reviewed revealed that staff were trained on infection control measures and the facility has implemented guidelines. Therefore, there was insufficient evidence to corroborate with this allegation.