complaint·July 31, 2024

Continued from 9099... Facility caregiver stated to interviewed witnesses, that resident frequently urinates. Witnesses interviewed explained that licensee advised them of the same thing, that this resident frequently urinates so they cannot always be kept clean and dry. LPA interviewed licensee and caregiver at facility, both explained that resident frequently urinates and is on an incontinence brief changing schedule. Resident is on a changing schedule as they require medication previous to their being changed because they experience pain when being repositioned. Caregiver explained that the resident gets changed by our schedule which is: between 9am and 10am after morning shift caregiver serves all other residents’ breakfast, at noon if resident needs it, at 4pm, at 8pm, then at 10pm or midnight depending on when afternoon caregiver leaves the facility. So, between 10pm or midnight until 9am the next day resident is not changed. Per review of resident’s hospice care plan, resident is to be repositioned every 3 to 4 hours for pressure relief. Hospice care plan also specifies that resident is to have an incontinence check every 3 to 4 hours to mitigate skin breakdown. However, per interview with licensee and caregiver, resident is not attended to for anywhere between 9 and 12 hours overnight. Therefore, based on LPA's observations, photographic evidence, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited on the attached LIC9099D.