Complaint Investigation Report

On 10/31/2025, from 09:40 a.m. to 01:30 p.m. LPA conducted a physical plant tour, interviewed staff and residents while on site for a separate investigation. On 11/17/2025, LPA received and reviewed hospital records for Resident #1 (R1).

It was reported that “staff do not ensure that the facility remains free of odors” and “staff do not ensure resident’s room is clean and sanitary” as it was alleged that R1’s room was observed to smell of urine like a “dog shelter” and that clothes were all over the floor. On 06/06/2025, at approximately 9:45 a.m., during a physical plant inspection, the LPA observed a urine odor coming from Resident #1’s (R1) room and observed unfolded clothing scattered on the bed. At approximately 9:50 a.m., the LPA observed Staff #1 (S1) mopping the hallways and common areas. During an interview, S1 stated that the floors were being mopped due to an odor originating from R1’s room. S1 further stated that R1 had thrown their clothing on the floor and that S1 had placed the clothing on the bed. Interviews and observations conducted during the course of the investigation revealed that flies were observed on multiple occasions in common areas and resident bedrooms due to trash cans not being emptied and food debris on counter tops. Based on information gathered during the investigation, the department has sufficient evidence to confirm these allegations occurred. Therefore, the allegations that “Staff do not ensure that the facility remains free of odors” and “Staff do not ensure resident’s room is clean and sanitary” have been deemed Substantiated at this time.

It was reported that “Staff do not ensure resident was assisted with dressing”, “Staff do not ensure resident’s hygiene needs are being met” and “Staff do not ensure resident’s showering needs are being met” as it was alleged that R1 was observed laying naked on top of bed and staff did not dress them in a timely manner, R1’s toenails were observed to be long and R1 was observed to appear to not have been showered for an extended period of time. On 06/06/2025, at approximately 9:45 a.m., during a physical plant inspection, the LPA observed a resident in bed without clothing, with a sheet covering the torso and waist area. During an interview, S1 reported that attempts were made on two occasions that morning to assist the R1 with dressing; however, the R1 removed the clothing each time. Staff further stated that the R1 was left alone with the intent to attempt dressing again later, but the R1 subsequently fell asleep.