Complaint Investigation Report

Regarding the allegation that staff do not treat residents with dignity or respect: it was alleged that residents go to dinner without shoes and without showering for days, facility staff argue with and intimidate residents who bring up concerns at resident council meetings, and facility staff stand around gossiping about residents and disclosing their confidential information. LPA observed one resident walking around the facility barefoot on January 10, 2025, and the same resident walking around the facility wearing only socks on January 13, 2025. Per COO, the facility has not received complaints about residents going without shoes and has not addressed this issue with any residents. LPA did not observe any residents with offensive odors throughout the facility and out of 13 residents interviewed, none had offensive odors and none reported concerns regarding showers or the hygiene of other residents when asked if they were experiencing any problems at the facility. Per COO, residents receive showers twice a week, some residents refuse but facility staff can usually work with them and convince them to shower. LPA reviewed the facility’s shower log for December 2024 which shows only four shower refusals for the month. LPA interviewed 13 residents, none of whom corroborated that staff argue with or intimidate residents at the facility. However, two residents reported witnessing staff making fun of a resident who has issues with speech by mimicking them and one resident reported that staff shared personal information about how this resident developed their issues with speech. The information obtained corroborated the allegation.

Regarding the allegation that staff allow residents to smoke in areas not designated for smoking: it was alleged that residents are allowed to smoke in their rooms leaving the building smelling like smoke. LPA inspected the facility and noted a strong smell of cigarette smoke coming out of one room and Resident #1 (R1) smoking in the front courtyard of the facility where there are multiple “no smoking” signs with dozens of used cigarettes and a lighter on the ground near R1. LPA reviewed the facility’s house rules which state that smoking is only allowed in the designated smoking area and smoking is prohibited inside the building and where there are “no smoking” signs. When interviewed, COO stated the only designated smoking areas are in the central courtyard and residents are not allowed to smoke in their rooms or anywhere else. COO could not provide information about the resident whose room smelled like smoke, but stated that R1 has been at the facility for about six months, facility staff tell R1 they can only smoke in the designated smoking areas but R1 does not listen, the facility is working with R1’s responsible party regarding this issue, and the facility has issued one written warning to R1 but has not issued an eviction notice.