Complaint Investigation Report

The facility did not promptly implement environmental infection control measures, as deep cleaning of the affected area was not conducted until January 9, 2026. Facility staff reported this delay was due to a lack of sufficient cleaning supplies.

On January 25, 2026, an unannounced visit was conducted by Licensing Program Analyst (LPA) Pascua. During the visit, no signage was observed indicating a suspected outbreak or isolation precautions within the affected area of the facility.

Interviews with staff and management revealed the facility did not maintain or follow a definitive infection control protocol. Staff reported reliance on general infection prevention knowledge from trainings received years prior and not specific to facility policies. Facility management acknowledged they were unaware of which infection control procedures to implement and stated they had not been provided with guidance. In addition, facility staff were given a copy of the facilities infection control protocol and facility staff stated they have never seen the infection control protocol during their time at the facility. However, a review of the facilities LIC9282 EMERGENCY INFECTION CONTROL PLAN states that a review was conducted by the Facility Administrator on 09/30/2025.

Further interviews revealed the facility did not notify Local Public Health and Licensing of the suspected outbreak, citing the absence of a confirmed diagnosis. However, per the Facility Regional Nurse, infection control protocols are to be initiated immediately upon identification of suspected cases, and notification to Local Public Health and Licensing is required upon medical diagnosis. Additional interviews confirmed the facility did not implement infection control protocols until additional residents developed rashes.

Based on the information gathered, the facility did not follow infection control protocols.

As a result of this investigation, the department found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.