Complaint Investigation Report

Review of Admission Agreement and Resident Statements indicated that R1 was being charged additional fees not outlined in the initial Admission Agreement. Review of email titled 30-day Assessment did not detail itemization of charges or detailed explanation of new services provided. Further interview with RP indicated that no subsequent evaluation was shared with them detailing the reasons for this increase in fee and attempts to conduct a care meeting with the previous ED were ignored or did not provide the information requested.

Licensee does not ensure that residents' laundry needs are being met – Reporting Party (RP) alleges that residents laundry/bedding is not being washed. Review of Resident Monthly Assignment Reports for August 2025 and September 2025 for resident (R1) indicated that the task “care partner to pull dirty laundry” was marked as XX and UND. Further review of Assignment Reports indicated that task “Staff to wash residents’ laundry…once weekly” was signed as completed. Interview with RDN indicated these markings mean no caregiver was assigned to these tasks and they auto closed. Further interview with RDN indicated that care partners are not tasked with completing laundry as this is a housekeeping task and is not tracked on the digital task list. Interview with staff (S1) indicated that staff were told that they are in charge of laundry, with the previous Executive Director (ED) telling them that “care staff should be doing things like taking out garbage, cleaning the room, and doing the laundry”. Further interview with S1 indicated that failure to do so resulted in disciplinary action. Interview with HWD indicated that care partners assisted with housekeeping and laundry until a new policy was enacted in September 2025, with care partners no longer having access to the housekeeping storage room in Memory Care. Review of R1’s Housekeeping Checklist for December 2025 indicated that the tasks “Strip & make bed” and “Remove dirty linens & replace” were marked with either an X or a slash for the entirety of the month. Interviews with housekeeping staff (S2, S3, and S4) indicated that these marking's meant the tasks were not completed. No resident refusals forms were completed during this time. Interview with RP indicated that no agreement was made for any outside party to complete R1’s laundry and facility was to handle all laundering.

Based upon observations, record review, and interviews, there is a preponderance of evidence to prove that the allegations have been SUBSTANTIATED and are valid.