complaint·July 11, 2022

LPA observed multiple photographs of soiled diapers, residents with wet and soiled clothing, and residents laying on wet sheets. Wellness Director stated when she reviewed the photographs, she stated it appeared residents were not changed for over 3-4 hours. LPA reviewed facility’s Plan of Care (POC) Response History documents which indicates staff did not respond to residents incontinence care. Resident 1 was missing a conformation of incontinent need met for one shift on 6/9/22, 6/11/22, 6/12/22, 6/15/22, 6/18/22, 6/19/22, 6/21/22 and 6/22/22. Resident 2 and Resident 3 were missing a conformation of their incontinent needs being met for one shift on 6/11/22, 6/12/22, 6/15/22, 6/18/22, 6/19/22, and 6/20/22. Resident 4 was missing a confirmation of incontinent need met for one shift on 6/11/22, 6/12/22, 6/16/22, 6/18/22, and 6/21/22, Resident 5 was missing a confirmation of incontinent need met for one shift on 6/16/22 and 6/21/22. Resident 6 was missing a confirmation of incontinent need being met for one shift on 6/16/22, 6/17/22, 6/18/22, 6/19/22, and 6/21/22. Resident 7 was missing a confirmation of incontinent need met for one shift on 6/15/22, 6/16/22, 6/19/22, and 6/21/22. Resident 8 was missing a confirmation of incontinent need met for one shift on 6/11/22, 6/16/22, 6/19/22, and 6/21/22. Resident 9 was missing a confirmation of incontinent need met for one shift on 6/11/22, 6/16/22, and 6/21/22. Wellness Director stated they held a meeting with staff to address the diapering issues on 6/14/22 at 2pm for 30 minutes. A follow-up meeting was held on 6/27/22 at 2pm to address the issue again. Wellness Director stated they also addressed the issue with the NOC staff. Based on interviews, record review, and photographs, the allegation is deemed Substantiated at this time. On the allegation: Facility does not have adequate hygiene supplies. The RP stated staff take briefs and wipes from other residents when residents run out of supplies and the facility staff do not restock them. Multiple staff interviewed indicated hospice residents do not have enough briefs and they take brief from other residents. Multiple staff stated they notify the med tech the resident is out of briefs, but it takes hours for the med tech to restock the briefs. Some staff stated there is also a delay in receiving briefs when notifying hospice more briefs are needed. Wellness Director admitted it’s difficult for hospice residents to get restocked with briefs and wipes. Based on interviews, the allegation is deemed Substantiated at this time. Exit interview, deficiency cited on 9099-D, report emailed, appeal rights emailed.