On the allegation Staff do not prevent the spread of a communicable disease it is the concern of the Reporting Party (RP) that the facility failed to prevent the spread of a “super bug”. To investigate this complaint LPA conducted in person interviews, telephonic interviews, file and record review and obtained copies of pertinent documents relevant to the investigation.

Interview with staff revealed that infection control protocols are followed when a communicable disease is identified; however, staff stated that this has not occurred in a long time and referenced COVID as the last instance. Staff #1 (S1) reported, “I have been here for about a year and have not experienced anything like that yet.” Staff also stated that they receive regular training on infection control procedures and described the protocols, including the use of personal protective equipment (PPE) when entering and exiting a resident’s room, maintaining a PPE station outside the room, posting signage on the door, and isolating or quarantining the resident as necessary. Staff further noted that the facility is well-maintained and routinely cleaned, with common areas cleaned regularly to ensure safety and cleanliness. Additionally, staff interviews demonstrated that staff are knowledgeable about infection control practices, policies, and procedures.

Interviews with the Resident Services Director (RSD) and the ED indicated that the facility has not identified any communicable disease within the community, and that the Department would be notified if one were identified. Resident interviews indicated that residents have observed staff following infection control practices, including wearing gloves or masks when appropriate. Residents stated that staff remind them to wash their hands or use sanitizer, and that staff regularly clean and disinfect common areas. Resident #2 (R2) stated, “The facility is always clean; they over-clean.” Residents also expressed that staff encourage them to stay in their rooms when feeling ill to help prevent the spread of illness.

Records review revealed that the facility’s infection control plan is complete and updated annually as required. The facility’s policies and procedures related to infection control meet regulatory standards. LPA reviewed incident reports submitted one month before and one month after the complaint to determine whether there was any indication of a “superbug”; however, none were found. Report continued on LIC 9099-C...

Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff do not prevent the spread of a communicable disease is deemed unsubstantiated at this time.

On the allegation Resident developed a UTI due to staff neglect it is the concern of the Reporting Party (RP) that the facility staff did not notice the symptoms of the UTI before hospitalization. To investigate this complaint LPA conducted in person interviews, telephonic interviews, file and record review and obtained copies of pertinent documents relevant to the investigation.

Interview with the Authorized Representative (AR) revealed that they were pleased with the care the facility provided to R1. The AR stated, “There was no way for them to know they had a UTI unless they went to the doctor and took the test. The facility acted appropriately. The first sign they noticed was the odor of the urine, and R1 was transported to the hospital.” R1 was unable to be interviewed, as they no longer reside in the community.

Staff interviews indicated that on 03/27/26, R1 appeared weak, and staff observed a strong odor during urination. Staff identified the concern, contacted 911, and R1 was transported to the hospital for evaluation, where they were admitted for a UTI. Staff reported that R1 was generally independent and required minimal assistance. Staff stated they cued R1 for toileting approximately two to three times per day.

Resident interviews revealed that when assistance with toileting is needed, staff respond promptly. Residents stated they receive adequate support to remain clean and comfortable, and their care needs are being met. No concerns regarding care were reported.

A records review showed that R1 required cueing for toileting independently or assistance with emptying the urinal or bedside commode. Staff were responsible for cueing R1 to use the bathroom for toileting or to empty the urinal/bedside commode as needed. The goal was that R1 maintained proper hygiene with assistance of staff 2 times per day. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Resident developed a UTI due to staff neglect is deemed unsubstantiated at this time.

Exit interview conducted. Report was reviewed and a copy was provided.