complaint·December 9, 2021

The investigation revealed the following: Resident changed another resident's diaper while in care It was alleged that a resident changed another resident’s diaper due to staff not changing the resident’s diaper in a timely manner. Seven (7) out of eight (8) residents interviewed stated that they did not know of any incident like this. One (1) resident stated that resident R6 kept screaming in the middle of the night for staff to change the diaper, so the resident changed R6's diaper. R6 denied this, stating only staff have changed R6's diaper. All staff interviewed denied the allegation with one (1) staff stated that they were told by a resident that this happened but did not witness it or know if it's true. Facility has inadequate record keeping It was alleged that staff are not maintaining adequate records including diapering logs. LPA obtained a copy of diapering logs for 3 specified residents. Diapering logs included the date, time, and initial of staff that conducted the diaper change. LPA observed that the logs were maintained daily and logs indicated that diapering took place for residents throughout the day. Interviews with staff reveal that four (4) out of six (6) staff stated that record keeping of diapering was maintained, while two (2) out of six (6) stated that it was not maintained accurately by all staff. Residents interviewed were not aware of this. Staff are not meeting the diapering needs of the residents It was alleged that staff are not changing resident’s diapers when needed at each shift. A review of the diaper logs for 3 residents shows that diaper change logs are filled out and completed throughout the day. The administrator stated that diaper checks are done every 2 hours and residents are changed as needed. Staff on each shift are responsible to check and change diapers. Four (4) out of six (6) staff interviewed stated that all staff meet the diapering needs of residents, one (1) out of six (6) stated diapering needs were not met by nighttime staff, while one (1) was unsure regarding this issue. Four (4) out of eight (8) residents interviewed stated that their diapering needs are met, three (3) out of eight (8) stated that their diapering needs are not met at night, and one (1) was unsure and does not wear diapers. A review of the needs and services plans for the residents who stated that their diapering needs are not met show that they are continent and able to use the restroom on their own. ***Continued on LIC9099C*** Staff did not prevent a resident on resident altercation It was alleged that on 7/13/21, two (2) residents had a verbal altercation and staff did not intervene when informed by another resident about the incident. Interviews with residents reveal: one (1) out of (8) eight residents stated that staff did not intervene during the resident altercation, one (1) stated that staff sometimes intervene, while six (6) out of eight (8) residents interviewed stated that they were not aware of this incident but that staff do intervene during resident altercations. The two (2) residents allegedly involved in the altercation did not recall the incident. Four (4) out six (6) staff were not aware of this incident but state that staff do intervene in resident altercations, while two (2) out of six (6) staff stated that staff went to check on the residents but it had already de-escalated and did not develop into a serious incident. Based on interviews and records reviewed, although the allegations 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 allegations are UNSUBSTANTIATED . An exit interview was conducted with the administrator, and a copy of this report and appeal rights provided.