Complaint·November 23, 2021

During the investigation, LPA Charitra interviewed staff, reviewed R1’s documentation and file, and inspected the bedroom. Interviewed staff indicated that R1 was admitted back in January of 2016 as an “independent” resident. The file review revealed that the continence products will not be used, although according to staff, R1 required briefs and pull-ups. The interviews also revealed that R1 had a history of urinating in his/her clothes. This resulted in an increase in the frequency of checks and elevating R1’s condition to a Level 2, requiring the use of additional changes of underwear and the use of pull-ups. Nevertheless, the licensee failed to update the physician report and/or to reappraise in order to develop an appropriate care plan to address R1’s health changes. The department received several reports that on the day of the incident, the room where R1 was found was disheveled and there was a strong smell to urine. R1’s r oom was inspected by LPA Charitra on October 27, 2021, 10-days after the incident. The windows were closed, the room was in disheveled and there was a strong smell to urine. According to the Administrator, the windows were closed due to a storm that took place on October 24th, a week and after the incident occurred. The mattress had been removed and yet the urine smell was strong. On November 10, 2021, almost three weeks after the incident, LPA Charitra and Investigator Phung conducted another unannounced visit to the facility and observed the resident’s room. The bed frame had been removed, and windows were observed to be open. The urine smell is still in the room. The facility incident report only acknowledges that the resident had an accident on 10/17/2021; however, the information collected provides preponderance of evidence to indicate that R1’s had been experiencing incontinency for some time . Based on the above information and documentation, it was determined that the licensee failed to document R1’s health changes and consequently failed to meet R1’s needs and failed to provide appropriate care and assistance. Furthermore, the licensee failed to assist resident with incontinence care and failed to maintain the resident’s room in sanitary condition. The preponderance of evidence standard has been met; therefore, these allegations are Substantiated. The following deficiency was cited per CA Code of Regulations Title 22-refer to the 9099D and appeal rights were provided. Therefore, based on the information collected, and interviews, the allegation that the licensee failed to address the resident’s diabetes is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.