Complaint Investigation Report

Interviews conducted and records reviewed reflected that staff routinely clean common areas and client bedrooms between approximately 6:00 a.m. and 10:00 a.m., after clients have showered, eaten breakfast, and departed for their day programs. Interviews further revealed that staff complete an additional round of cleaning in the evening after clients go to bed, typically between 10:00 p.m. and 11:00 p.m. Interviews with staff members revealed that one (1) client exhibits behaviors that include defecating on the floor in the client’s bedroom and common areas, and smearing feces on facility walls. Staff stated that when these incidents occur, the client is redirected and assisted with hygiene needs, and the affected areas are cleaned and sanitized immediately. LPA conducted interviews with family members/responsible parties of clients in care. No concerns were expressed regarding staff’s ability to maintain the cleanliness and sanitation of the facility at this time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, "Staff do not ensure the facility is kept in sanitary conditions for clients in care ” is deemed Unsubstantiated at this time.

It was reported that "Staff do not ensure the facility is kept in good repair" as it was alleged that there are exposed wires on the floor and one of the bedroom doors were in disrepair. During the physical plant inspection, LPA and QAS observed a long cable lying on the floor in the office area. The cable appeared tangled; however, it was located in an area not typically accessed by clients and did not pose an immediate health or safety risk to clients in care. LPA and QAS advised the Administrator to obtain appropriate cable management equipment to better secure and organize the cable. LPA and QAS observed all facility doors to be in good repair at the time of inspection. Records reviewed revealed a self-reported incident received on 04/30/2026, which documented that on 04/30/2026, Client #1 (C1) engaged in behaviors that resulted in damage to Client #2’s (C2) bedroom door. Records and interviews indicated the door was repaired on 05/01/2026.In addition, LPA's interviews family members/responsible parties of clients in care revealed they each did not have concerns regarding the facility not being kept in good repair. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, "Staff do not ensure the facility is kept in sanitary conditions for clients in care “Staff do not ensure the facility is kept in good repair” is deemed Unsubstantiated at this time.