Complaint Investigation Report

Regarding Allegation #1 : Staff did not keep a resident’s room free from odor.

This complaint alleged staff did not keep R1 room free from odor. LPA Calderon conducted an interview with A1. A1 states that R1 refuses to allow staff to clean R1 room or allow pest control to spray for fruit flies. A1 states that staff cleans R1 room and attempts to control the odor in R1 room. LPA Calderon conducted an interview with S1-S2. 2 out of 2 staff state that R1 refuses to allow staff to clean R1 room. 2 out of 2 staff state that when R1 is not in R1 room staff cleans R1 room. 2 out of 2 staff state that staff attempts to control the room odor but due to R1 urine it is hard to control odor in R1 room. LPA Calderon conducted an interview with R1-R4. 4 out of 4 residents were not capable of answering any questions due to health issues. On 12/13/2023 LPA Calderon toured the facility with A1. LPA Calderon noted R1 room had an odor of urine. LPA Calderon noted R1 in soiled pants while inside R1 room.

Regarding Allegation #2 : Staff did not properly maintain a resident’s bed while in care.

This complaint alleged staff did not maintain bed for R1. LPA Calderon conducted an interview with A1. A1 states that R1 does not allow staff to clean his bed or change R1 mattress sheets. LPA Calderon conducted an interview with S1-S2. 2 out of 2 staff state that R1 does not allow staff to clean R1 bed. 2 out of 2 staff state that when R1 is not inside R1 room staff changes R1 bed sheets. 2 out of 2 staff state that R1 does not allow staff to put plastic sheet on the bed to protect the mattress from R1 urine. On 12/13/2023 LPA Calderon toured the facility with A1. LPA Calderon noted that R1 bed had a urine spot. Appears R1 had urinated in the bed. LPA Calderon noted R1 bed mattress was soiled and ripped up and needs to be replaced. LPA Calderon noted that staff wanted to put clean sheets on R1 wet bed without addressing the urine spot in R1 mattress.