Complaint Investigation Report

The investigation revealed the following: It is alleged that the facility did not notify residents and families of the water shut off. Per the interviews conducted, three out of the five residents confirmed no notice was given ahead of time regarding the water shut off on repair dates January 14, 2025 and January 15, 2025. Six out of the seven staff also corroborated with the allegation. Based on the review of the emails, ED was informed on January 7, 2025 at 12:06pm for the repair scheduled on the 14th allowing ample time for the residents and their families to be notified by the facility.

Regarding the allegation, facility did not follow the infection control requirements, it is alleged that the facility did not maintain hand sanitizers or wipes for the residents to perform proper hand hygiene during the water shut off. Facility maintained sufficient supply of hand sanitizers in the medication rooms and supply rooms per inspection conducted on the 16th. Also observed in the housekeeping rooms, were barrels of clean water at each level available for cleaning and for resident use. Per observations, hand sanitizers and/or wipes were not observed in the residents' rooms and common areas making it inaccessible for residents and staff to sanitize their hands. Based on the interviews, four out of the five residents corroborated indicated not being able to wash or sanitize their hands with an alcohol based sanitizer and/or wipes while one resident maintained their own hand sanitizer in their room. Six out of the seven staff denied the allegation indicating that proper hand hygiene were practiced such as wearing gloves and using hand sanitizers while assisting residents while the water was shut off. Five out of the seven staff also confirmed providing hand sanitizer to the residents as needed. Based on observations and information obtained, it is determined that the residents were unable to practice proper hand hygiene during the repairs which could have been prevented if hand sanitizer dispenser stations were available and/or carried by the staff to deter theft and ensure easy access.

Therefore, based on LPA's observations, interviews which were conducted, and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations, Facility did not notify residents and families of water shut off and Facility did not follow the infection control requirements are deemed SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D.

An exit interview was conducted with Executive Director Dennis Robeniol, and a copy of this report including the LIC9099-D, and the appeal rights were provided at exit.