Complaint Investigation Report

On 4/9/25 at 1pm LPA conducted a tour of the facility, which included inspection of 5 bedrooms, 8 mattresses, 4 bathrooms, kitchen, and pantry. On 4/17/25 from 11:35am-11:45 LPA conducted interview with Client #1 C1. On 04/17/25 LPA conducted medication review for C1, and on 4/17/25 from 1pm-1:45 pm am LPA conducted interview with staff #2-4 (S2-S4). On 4/9/25 and 4/17/25 LPA was unable to interview S1, as S1 was not on site during visit.

Allegation: Staff did not ensure resident’s mattress is clean and in good repair.

It is being alleged that client in care has been sleeping on a mattress that has urine and feces stains .

On 04/09/25 from 10am-11:22 am LPA conducted interviews with C2-C5, 4 of 4 clients interviewed denied the allegation above. On 04/09/25 from 11:25am-12 pm LPA conducted interview with L1 regarding the allegation above, L1 denied the allegation above. Per L1, all mattresses have a mattress cover that are replaced when a new client is admitted, L1 continued to report that L1 keeps a supply of new mattresses in a different location, and if a new mattress is needed it can take 3 days to be transported to the facility. On 4/9/25 at 1pm LPA conducted a tour of the facility, which included inspection of 5 bedrooms, 8 mattresses, LPA observed mattresses to be clean, mattress covers appear to be in good repair. On 04/17/25 from 11:35am-11:45 am LPA conducted interview with C1 regarding the allegation above, C1 confirmed the allegation above and reported the mattress client was sleeping on was dirty and stained but has since been replaced. On 04/17/25 from 1pm-1:45 pm LPA conducted interview with S2-S4, 3 of 3 staff interviewed denied the allegation above and reported that mattresses are replaced as needed. On 4/9/25 and 4/17/25 LPA was unable to interview S1, as S1 was not on site during visit. On 04/17/25 LPA conducted a review of mattress factory invoices dated 1/22/25 which indicates 4 full size size mattresses, and 5 metal bed frames where purchased.

Allegation: Staff threatened to evict resident.

It is being alleged that facility staff told client in care that eviction paperwork was going to be prepared. On 04/09/25 from 10am-11:22 am LPA conducted interviews with C2-C5, 4 of 4 clients interviewed denied the allegation above. On 04/09/25 from 11:25am-12 pm LPA conducted interview with L1 regarding the allegation above, L1 denied the allegation above and reported that clients are not threatened with eviction. Per L1, if a client reports being unhappy at the facility L1 reminds clients that they have the option to move out but they need to provide L1 with a 30 day notice. On 04/17/25 from 11:35am-11:45 am LPA conducted interview with C1 regarding the allegation above, C1 confirmed the allegation above and reported being threatened with eviction after asking for a new mattress. On 04/17/25 from 1pm-1:45 pm LPA conducted interview with S2-S4, 3 of 3 staff interviewed denied the allegation above. On 07/17/25 LPA conducted a file