Complaint·February 21, 2025

Allegation #1: Staff leave resident in wet diapers for extended periods of time. The details of the complaint alleged that facility staff are not changing resident's diapers, resulting in residents experiencing rash and burning. The department interviewed the administrator (A1), stated that the facility has a schedule, and that the facility staff also changed the resident's diapers as needed. The department interviewed six residents (R2-R7) 4 out of 6 residents stated that the staff regularly changed their diapers, including incontinence services. The department interviewed six staff (S1-S6), 6 out of 6 stated that the facility has a diapers and incontinence schedule, and in addition, the facility staff changes residents' diapers every 2 hours and as needed. The department records review of facility changing diapers and incontinence services dated 04/01/24 to the present indicated that all the residents who wear diapers have a scheduled time to check and change diaper services between one to two hours seven days a week. The department was unable to interview (R1). Based on the interviews, observation, and record reviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated Continued LIC-9099-C Page 2 Allegation: Staff do not respond to resident’s calls for assistance in a timely manner. The details of the complaint alleged that the resident called the night shift, and the staff failed to respond in a timely manner. The department interviewed the administrator (A1), who stated that the facility staff tends to the residents' needs as fast as possible, even in the middle of the night, between 5 to 10 minutes. Additionally, (A1) stated they encourage all staff to answer the Emergency Call System (ECS) if they hear it ringing. A1 stated they have five (5) residents who usually call the facility, averaging 150 times per shift, for assistance just to get the TV remote or to close the bathroom door (etc.) for them. In interviews with six Staff (S1-S6), 6 out of 6 stated if they are available and if they hear the (ECS), they will answer it. The staff also stated that the resident must initiate the (ECS), and the caregivers or the Medical Technician (MedTech) would assist the resident. The department inspected four residents' bedrooms, #219, #220, #303, and # 313, and found that the (ECS) was accessible to residents, and once pressed, the facility staff answered in less than a minute. The department confirmed it. The department interviewed six residents (R2-R7) 5 out of 6 residents interviewed indicated that they had used the (ECS) and that staff members had assisted them in less than five minutes. Once the (ECS) is pushed, the system sends an alert to the MedTech station and the caregiver's cell phone for assistance. The MedTech or the caregivers were notified of the alert and went to the resident's room to assist. The department was unable to interview (R1). Based on the interviews, observation, and record reviews, there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited. The exit interview was conducted, and a copy of this report was given to Administrator Maria Bravo.