Complaint Investigation Report

The investigation revealed the following : Allegation #1- Staff do not ensure facility has current fire extinguishers.

The details of the complaint alleged that the facility does not ensure that fire extinguishers are properly maintained. It was reported that the fire extinguishers have not been serviced or replaced for several years. On 12/4/2025, from 9:30am-3:00pm, the department interviewed staff (S1-S4) regarding the allegation. 4 of 4 staff denied the allegation that Staff do not ensure facility has current fire extinguishers. All staff stated that the fire extinguishers were recently serviced and that they have not observed any that were outdated.

The department reviewed the A & A Fire Protection Invoice (Dated: 10/15/24) and observed that they were serviced on 10/15/2024.

The department toured the facility and observed that there was a total of 16 fire extinguishers throughout the facility that were recently serviced on 12/2/2025 and all were fully pressurized. Three in the lobby, two in the kitchen, three on the first floor, three on the second floor, three in the garage, one in the storage room, and one in the elevator mechanical room. The facility has not received an invoice for the current year.

Based on observation, interviews, and records reviewed, there is insufficient evidence to support the allegation that Staff do not ensure facility has current fire extinguishers. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated .

The details of the complaint alleged that the facility is malodorous. It was reported that the facility smells of incontinence, especially on the first floor and in memory care. On 12/4/2025, from 9:30am-3:00pm, the department interviewed staff (S1-S4) and residents (R1-R8) regarding the allegation. 4 of 4 staff denied the allegation that the Facility is malodorous. All staff that were interviewed stated that the facility ensures that the building is free from foul odors like urine, incontinence, and hygiene-related odors on all floors. They further stated that the facility has a housekeeping checklist that the housekeepers follow as well as a caregiver workflow schedule to ensure the facility is cleaned and has no lingering smells.

The department interviewed residents (R1-R8) about the allegation and 8 of 8 residents that were interviewed stated that they have not smelled any foul odors that lingers for a long time in the facility.

The department reviewed the RCFE Caregiver Morning Shift Workflow (Dated: 6:00am-2:00pm), RCFE Caregiver Morning Shift Workflow (Dated: 2:00pm-10:00pm), and RCFE Caregiver Morning Shift Workflow (Dated: 10:00pm-6:00am) and the House Keeping Daily Checklist (Dated: November/December 2025) and observed that the facility has a round the clock schedule of staff that are tasked at making sure the facility remains clean.