complaint·August 5, 2024

Based on the facility shower log for the month of April it was learned that four residents were not receiving showers by the facility. It was also learned that some residents did not receive shower a week after the previous shower. LPA Lee also reviewed End of Shift Report and it was learned that on 04/19/2024 resident 1 (R1) was upset because the shower schedule is inconsistent and that (R1) wanted a shower. Based on observations on 07/29/2024 at 9:14 AM, LPA Lee observed (R1) and (R2) call lights turned. It was learned that (R1) was waiting to get assistance with toileting and (R2) was waiting to get assistance with changing (R2) incontinence brief. At 9:26 AM, LPA Lee observed two Resident Aid (RA) walked by both (R1) and (R2)’s room without acknowledging and checking on both resident even though their call lights were turned on. At 9:46 AM, Administrator Assistance, Katelyn Becker approached LPA Lee and LPA Lee informed Katelyn about what LPA Lee have observed and that two residents needed assistance with their ADLs. At 9:54 AM (R1) stopped a (RA) who walked by her to get assistance. It took 37 minutes before a (RA) assisted (R1) with toileting. At 9:54 AM, LPA Lee observed a (RA) going into (R2)’s room to assist (R2) with changing (R2)’s incontinence brief. It took 40 minutes before (R2) received the assistance with changing (R2)’s incontinence brief. Per (R1)'s LIC 602 Physician Report (R1) needs assistance with set for toileting. Per (R2) LIC 602 Physician Report it was learned that (R2) wears brief and needs one person assistance for toileting needs. Moreover, LPA Lee and administrator Caleb toured the facility for an annual inspection on 07/29/2024 and observed resident room 213 and room 110 to have a very strong urine odor. LPA Lee pointed out to administrator regarding the strong urine odor in both rooms and LPA Lee asked administrator what does it mean if a resident's room has a strong urine odor and administrator Caleb stated, "it means the resident are not getting changed or cleaned." As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Nurse Mel and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.