Complaint Investigation Report

Records Review demonstrated that facility staff put in work orders for maintenance for R1's hospice equipment on 01/23/25, 01/28/25, 04/10/25, 08/23/25, and 09/05/25. Per the Hospice Inventory item pickup, dated 11/19/2025, R1 had the following equipment for use from 04/10/25 until R1 moved out of the facility on 11/19/25: two fall pads, hospital bed, over bed table, two half rails, mattress, recliner, 2 foot rests, high back wheelchair, and a pommel cushion.

Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.

On 08/12/2025 it was alleged that "Staff did not dispose of waste in a proper manner" The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, and records review.

Regarding the allegation, "Staff did not dispose of waste in a proper manner", it was alleged that facility staff do not clean the room on a regular basis which resulted in leftover fecal wipes in a resident's room.

Interviews with staff demonstrated that staff are aware of the housekeeping schedules and proper sanitation requirements when providing care for residents. S1 stated, "twice a week that rooms are deep cleaned." With regards to continence care, fecal wipes are disposed in resident waste baskets and after each brief change, the plastic bag goes with caregivers to be delivered to the trash room.

Interviews with Residents conflicted on the cleanliness within the facility. R2 stated that facility staff do not keep the facility clean but clarified that meant staff don't change the linens often enough. R3 stated that the facility was clean and stated their observations that staff are "always sweeping the hallways" or "cleaning up R3's room" when they provide care for them.

Records review of housekeeping records demonstrated that care staff regularly cleaned R1's room during the time period of the complaint.