Complaint·April 19, 2024

Review of medical and assessment records dated 2020 for Resident 1 (R1) revealed that R1 had a diagnosis of mild cognitive impairment, was not confused or disoriented, was able to communicate needs, required staff assistance for transferring, showering, and toileting care and did not have a bowel or bladder impairment. Interviews with staff and outside sources revealed that R1 required the use of a walker and wheelchair and used incontinence briefs. Interviews with multiple staff revealed that staff would check on residents who used incontinence briefs and change the residents' incontinence briefs multiple times a day. Staff stated that staff would occasionally check on residents overnight if the staff member woke up during the night but would not awaken residents for brief changes if the residents were sleeping. Staff stated that staff would be able to hear if residents called for assistance overnight and that some residents would occasionally call for assistance during the night. Outside sources voiced concerns during interviews that R1 would be left seated on the toilet for long periods of time but did not provide the Department with any description of the length of time. Additionally, an outside source provided information during an interview that R1 required additional time to finish using the toilet. Interviews with staff and outside sources provided conflicting information regarding R1’s ability and tendency to notify staff when R1 needed staff assistance to use the restroom, get up from the toilet, or needed R1’s incontinence briefs to be changed. Staff could not recall any complaints from residents, including R1, regarding not receiving incontinence care, not receiving incontinence care overnight, or being left in soiled briefs or clothing. The Department was unable to interview R1 due to R1 passing away prior to being interviewed. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Licensee Cheryl Castro, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).