Complaint Investigation Report

It was alleged that Resident's room was not properly maintained and R1’s care had been neglected during their time at the facility as there was a terrible smell coming from inside the room. It was reported that Resident 1’s (R1’s) room was unkept and the room smelled like urine and feces. It was further reported that inside the room were a water bottle that had mold, soiled clothes stacked in the tub, and rotten trash that was not taken out. Interviews with R1’s family members revealed that they were ‘appalled at the state of their room’. Interviews with the staff revealed that housekeeping is done once a week and reported that ‘sometimes caregivers will call housekeeping if a resident’s room is too dirty in between’. Interviews with residents confirmed that housekeeping is done once a week. Additionally, interviews with residents revealed that everything gets charged, ‘if it is not in your care plan, they will add it to your bill’. Correspondingly, interviews with random resident family members revealed that when they have previously visited, the room is not messy, although it could be a bit cleaner. Also, Interviews with random resident family members revealed that they had visited the resident and the smell of urine was lingering around and were concerned as they stated, ‘the bed is still wet while they’re lying there…’. They had previously requested a fan to dry out the mattress because they were only making the bed but not drying it out. Interview with the ED revealed the facility was not short staffed due to the pandemic and if they were short staffed, agency staff came in and helped out when needed. Additionally, the level of care displayed what services came standard. As far as laundry and taking out the trash, that is a standard service that comes included in the level 4 care plan. Furthermore, record review revealed photos that of which displayed clothes all over the living room, mold on the straw of R1’s water bottle, and soiled clothes in the bathtub. Per Admissions Agreement signed on 1/17/2020, it states on page 5 of 44, under bullet point 2-Our Services, ‘we provide the following standard services for the stated monthly rate: weekly linen laundry service and cleaning of apartments’. However, R1’s room was not properly maintained while living at the facility. Based on the information and records obtained and reviewed, the allegation of “Resident's room was not properly maintained” is deemed Substantiated at this time. Additionally, based on interviews and record review, the allegation that “Resident was not provided a comfortable accommodations” is deemed Substantiated at this time.