complaint·June 26, 2025

Allegation: Staff did not ensure resident’s room was adequately cleaned. It is alleged resident (R1's) room is dirty and cluttered due to hoarding. According to information obtained, entrance into the room is blocked. A total of 17 rooms were inspected during today's visit. Two (2) out of the 17 rooms were dirty and cluttered with furniture and personal belongings. On 5/16/25, Licensing Program Analyst (LPA) inspected R1's room and observed many dead cockroaches, several alive cockroaches, old discarded food on the floor, pet hair, dirty floors, trash throughout the room, and bathroom bathtub full of clothing. According to staff interviewed, staff attempt to clean the resident's room but the resident refuses. Staff stated that housekeeping staff clean resident rooms once a week, and caregivers take out the trash daily every shift. A total of 11 residents were interviewed, of which on e (1) stated staff do not clean their room. None of the other residents had concerns. Resident (R1) stated they do not know why staff do not clean their room, but then acknowledged they refuse to allow staff to clean. Per Personal Service Plan dated 5/13/2025, facility staff have not assisted R1 with cleaning, picking up trash, putting clothes away, or dusting floor to remove dog hair. There is sufficient evidence to corroborate the allegation. Allegation: Staff did not ensure resident’s room was free from odors. It is alleged that resident (R1) has a dog in the room that defecates and urinates in the room and there is a "stench" that is smelled from the hallway when the door is opened. Housekeeping and caregiver staff stated R1's pet dog urinates and defecates in the room and confirmed bad odors. According to staff interviews, when the resident moved in pet services were in place, but R1 was able to take the dog out to potty. Therefore, pet services were stopped. Per facility's pet policy when pet services are in place caregivers walk the pet and clean up after the pet(s). Resident (R1) stated their room does not smell like dog feces or urine. None of the 11 residents interviewed stated their rooms have a strong odor. Based on R1's observations of R1's room, a strong odor of urine and feces was smelled . Based on document review, R1's Personal Service Plan "Pet Care" Resident has a dog and needs pet care assistance. Staff are to take dog fo r walks daily around 8AM, 12 noon, 4 PM, and 8 PM. Staff will monitor pet to see that they are provided adequate food and water. Although, pet services were stopped, in the updated Personal Service Plan dated 5/13/25 it was noted that staff will assist with pet care. Therefore, there is sufficient evidence to support the allegation. Allegation: Staff did not ensure resident’s room was free from pests. It is alleged resident (R1's) is infested with cockroaches and the facility has not addressed the issue. Four (4) out of the 11 residents interviewed stated they have seen cockroaches in their rooms. Resident (R1) stated there are cockroaches "everywhere in my room", but did not report it to Administration staff. A total of 5 staff were interviewed, of which all stated that they did not have knowledge of the cockroach infestation until this week. According to staff interviews, on Tuesday, May 13, 2025, staff went in to R1's room to remove the bed an observed the infestation of cockroaches under the bed. On Wednesday, May 14, 2025, Administration staff called Dewey Pest Control for services. During today's visit, Dewey Pest Control was observed addressing the problem in R1's room. LPA reviewed pest control service contract. They are scheduled to provide services twice a month and/or as needed. Record review revealed that the facility has on-going pest control services in place that focus on common areas, kitchen/dining room, and resident rooms identified in need of pest control mitigation. However, R1's room was not being treated by pest control despite housekeeping staff insight of room uncleanliness i.e. pet food waste. The first pest control room treatment was conducted on 5/16/25. Based on observation, photo evidence, and interviews, there is sufficient evidence to corro borate the allegation. Based on observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . An exit interview was conducted with Interim Executive Director/Operation Specialist Mario Preston. A copy of the report and appeal rights were issued.