Complaint·March 6, 2024

[CONTINUED FROM LIC 9099] Per R1’s LIC602 Physician’s Report, R1’s doctor determined that R1 was not confused/disoriented, able to communicate needs, able to follow instructions, and able to leave the facility unassisted. The doctor also wrote that R1 experienced urinary incontinence and had poor hygiene habits. R1’s LIC603A Resident Appraisal reinforced that they were bladder incontinent. Multiple staff interviews corroborated that R1 sometimes wet their bed, despite wearing pull-up/Depends underwear. According to regulation CCR 87464 (titled "Basic Services"), Licensee was required to provide “safe and healthful living accommodations.” According to regulation CCR 87307 (titled "Personal Accommodations and Services"), Licensee was required to provide “clean linen” for resident beds and ensure that “clean linen is in use by residents at all times.” According to the Admissions Agreement which R1 signed, R1 was their own responsible person and they agreed to allow Licensee's staff to periodically change their bed linens and provide basic housekeeping to their room. Staff interviews showed: During the time frame of the complaint, caregivers sometimes entered R1’s room to perform bed linen changes and basic housekeeping when R1 was not present (since R1 frequently went on community outings). There were times cleaning was urgent, due to R1 having wet their bed. R1 often left small personal effects on top of their bed and/or on the floor of their bedroom. To effectively change R1’s bed linens and/or sweep/mop the floor, staff sometimes relocated said personal effects into a cardboard box. The box was left inside R1’s bedroom in plan view for R1 to see upon their return. There was at least one occasion when staff observed the top of R1’s dresser was so filled with personal items that some (which included open containers) were at risk of falling on the ground. Staff similarly placed some of these items in a cardboard box. Staff interviews aligned to show that on occasions when staff touched R1’s belongings, their scope was limited to only those items which needed to be moved to support basic cleanliness for R1’s room. Cleanliness of R1’s bedroom supported R1’s dignity. Licensee provided open communication to R1 about the need to clean and made reasonable efforts to clean when R1 was present, although this was not always possible. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] In their own interview, R1 confirmed that facility staff did not remove their personal belongings from their bedroom or deprive them access to or use of their belongings. LPA’s observation of R1’s bedroom supported the credibility of staff accounts. LPA also interviewed three (3) additional residents in care; each person said that facility staff treated them with dignity and respected their belongings / personal property. Based on interviews and records, a preponderance of evidence does not exist to prove that Licensee did not afford R1 dignity. The allegation is therefore unsubstantiated. An exit interview was conducted with Gelindec and Ahmed. A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during today’s visit.