Complaint Investigation Report

S1 attempted a one-person transfer for R1, who is a 2-person transfer. Administrator stated they had left S1 and S2 alone with residents on 5/28/25. S1 and S2 had employment terminated.

The allegation regarding ineffective infection control was also made in and substantiated for complaint 59-AS-20251119202205. Therefore, though substantiated here, citation was issued for that complaint only.

Administrator stated that R1’s personal laundry and linens were not kept separate from other residents. R1’s linens would be, at times, be returned to the house’s linen supplies and used on other resident beds. Administrator also acknowleged that their dryer stopped working, clothes were hung to dry outside and the current dryer does not get sufficiently hot. During a contact precautions infection in the home, these instances constitute mishandling of resident belongings.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with . Copy of this report and appeal rights provided.