complaint·April 11, 2025

Allegation: Staff leaves resident soiled for an extended period of time. The allegation alleges that a resident was left in a soiled pull-up for an extended period of time. During the facility inspection, LPA observed Staff assisting residents to the bathroom, including R1. During record review, LPA received and reviewed the Physician’s Report for R1 dated 12/27/2023, that indicates R1 has a Bladder Impairment that requires pull-ups. Additionally, the Physician’s Report indicates R1 is not Able to Manage Own Toileting Needs. LPA received and reviewed Resident R1’s Assessment dated 02/10/2024 that indicates R1’s Toileting needs consist of the following assistance, Reminders, verbal cueing, Help with bathroom activities and hygiene, and Full assistance with all aspects of bathroom activities and hygiene. R1’s Assessment indicated Enhanced Needs for Toileting that consist of Assistance with morning, bedtime, and nighttime toileting; Unscheduled escort and assistance with toileting; Two-person assistance with toileting. LPA received and reviewed Resident R1’s current Care Summary that indicates for Toileting R1 requires Minimum- Reminders, verbal cuing, and Needs toileting schedule to be followed. R1 requires Assistance with morning and bedtime toileting, Assistance with AM, PM, and nighttime incontinence care. During interviews with Staff S1, S5-S11, were asked how often incontinent residents are changed and/or checked if they need to be changed, eight (8) out of eight (8) indicated residents are assisted with changing or going to the restroom every 30 minutes to 2 hours depending on the resident. Additionally, Staff S5-S11 was asked if they have come onto shift and had a resident who was soiled, two (2) out of seven (7) stated yes, they have come onto shift and had residents soiled. During interviews with Residents R2-R7, were asked if there was a time they were left in soiled pull-ups or diapers for an extended period of time, four (4) out of six (6) stated yes, they have been left in soiled diapers for an extended period of time. During interviews with Witnesses W1 and W2, were asked if they have come and observed their resident in soiled diapers, one (1) out of two (2) stated they have observed their resident in soiled diapers for an extended period of time. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Resident Care Coordinator, Robin Walker, and a copy of this report and Appeals Rights was provided.