Complaint Investigation Report

In regards to the allegation "Facility staff were not wearing masks." It was alleged that on 9/29/2022 at 12:30pm, W1 Ombudsman entered facility through front door and observed S2 without a mask. S2 stated only visitors are to wear a mask when entering the facility. S2 did not try to wear a mask despite having two (2) separate conversations regarding masking. During a previous visit by W2 on 6/14/2022, two Staff S3 and S4 were observed not wearing masks and no Covid screening done upon entry for an indoor visit.

On 10/05/2021, LPA conducted an unannounced visit and upon entry into the facility, LPA observed that S1 was not wearing a mask and did not perform the Covid-19 screening protocols: (a) temperature check (b) sign in (c) wash or sanitize hands. Shortly thereafter, S2 arrived at the facility and LPA observed that he was not wearing a mask either and did not wash hands or use hand sanitizer upon entry. LPA also observed R1-R2 not wearing a mask. LPA observed that S1-2 were providing care to the residents unmasked. LPA interviewed S1-2 and both stated that they never wear a mask because they are inside the facility and they did not know it was required. S2 stated that he does not like wearing a mask because it is hard to breathe and only visitors must wear a mask when they enter the facility. LPA attempted to interview R1-2 but both were unable to communicate coherently. LPA interviewed S5 over the phone and stated that she was not aware that the staff do not wear mask inside the facility. S5 indicated that she provides masks for the staff and it is difficult for her to monitor because she is not around every time. S5 stated that she trained the staff regarding Covid-19 screening and protocols but will re-train them. LPA interviewed S3 over the phone who does not work at the facility anymore. S3 acknowledged that he did not wear a mask and conduct the Covid-19 screening when W2 came to visit on 6/14/22 because he forgot. LPA interviewed S4 on the phone and stated she never wear a mask inside the facility.

On 10/07/2022, LPA conducted a subsequent visit and interviewed R3-R5. R3 stated that Staff never wear a mask. R3 also indicated that none of the staff did not wear mask when entering her room to serve food and give medication. R4-R5 who are both cognitively impaired stated that they were not sure and cannot remember if Staff wear mask inside the hou se. LPA also determined that the facility did not have an in-service training log for Infection Control Plan.