complaint·April 16, 2021

Allegation: Staff did not assist a resident with hygiene needs. It is alleged facility staff are changing incontinent residents diapers but is not changing the sheets when they are soiled. On 4/15/21, LPM Hammond and LPA Calderon interviewed Administrator Lesly Figueroa regarding the allegation, she stated she is aware that caregivers are changing incontinent residents diapers but not changing the linens when they are soiled stating that is the responsibility of the housekeepers. The Administrator stated she has explained she informed caregivers it is their responsibility to change the sheets not the housekeepers. On 3/12/2021 LPA Calderon interviewed R2-R10 that stated they were not aware of any issues with hygiene needs not being met. 03/12/2021 LPA Calderon interviewed S2- S6 and staff denied the allegation. On 03/17/2021, LPA received and reviewed physicians report for R1 and it indicates R1 needed assistance with incontinence care. LPA was unable to interview R1 as she is deceased.. On 04/15/2021 LPM Hammond and LPA Calderon interviewed S7 and S7 stated that there are major training issues regarding hygiene needs for all residents. On 4/15/21, LPM Hammond and LPA Calderon interviewed S8 regarding the allegation, S8 stated while on shift when R1s Hospice Nurse came to the facility and complained R1s diaper was clean but R1s sheets were soiled with feces and urine and had not been changed. S8 stated the staff went and changed the residents sheets. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. A telephonic exit interview was conducted with Administrator Lesly Figueroa, and a hard copy was provided via email for records