complaint·September 26, 2024

Allegation: “Resident is left soiled for an extended period of time:” The complaint alleges that R1 was not changed regularly. Review of R1’s physician’s report indicates that R1 does not have a bowel or bladder impairment, but that R1 is unable to care for their own toileting needs. The needs and service appraisal provided to LPA was incomplete and missing the pages related to incontinence care and assistance with toileting. Staff interviewed indicated that R1 requires assistance getting to the toilet and assist in changing R1’s briefs if needed by putting the briefs at R1’s ankles for R1 to pull up on their own. R1 utilizes the call light system when R1 requires toileting assistance. Staff stated that R1 regularly uses the call light and staff respond accordingly to assist R1. At the time of the initial complaint visit, R1 was hospitalized, and Administrator indicated that R1 only returned to the facility for a day or two prior to moving out of the facility. LPA attempted to reach R1 via telephone but LPA was unsuccessful. During an unrelated complaint visit on 04/05/2023, LPA observed staff assisting R1 in the restroom during the visit. Other residents interviewed felt their incontinence needs are being met and staff assist with toileting. Based on interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “resident is left soiled for an extended period of time” is deemed UNSUBSTANTIATED at this time. Allegation: “Resident has missed meals due to staff neglect:” LPA conducted interviews with staff and residents related to this allegation. Staff indicated that R1 used to consistently go to the dining room for all meals. Recently, R1 has been experiencing pain and does not wish to get out of bed in the morning to go to the dining room during breakfast hours. Staff stated they are bringing R1 room trays for breakfast for the last 2 (two) weeks or so instead. Care staff interviewed indicated kitchen staff prepare the trays, then the care staff bring R1 their room tray and they are not aware of a time when R1 did not get fed. Staff interviews revealed that R1 prefers hot breakfast, which is difficult as R1 does not get out of bed to eat until 10:00AM or 11:00AM and that breakfast is served at 07:00AM. Staff stated they bring oatmeal and juice to R1 and if R1 prefers a different choice, they will return to the kitchen and ask for an alternative. According to staff, R1 chooses not to eat lunch sometimes, per their preference. R1 reportedly told staff that they prefer to eat breakfast in the late morning, then they eat dinner in the dining room, with just a light snack in between when hungry. Staff indicated that when dining staff did not see a resident in the dining room, they prepare snacks for that resident, in case they were needed. LPA was Report Continued on LIC 9099-C (p. 3) unable to speak with R1, however, other residents interviewed indicated they receive all their meals and haven’t had problems related to obtaining food. Based on interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “resident has missed meals due to staff neglect” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff do not clean resident room timely:” The complaint alleges that R1’s room is left dirty and housekeeping is not provided regularly. R1’s needs and service appraisal indicates “daily housekeeping, deep cleaning once weekly.” During all of LPA’s facility visits, LPA has observed housekeeping staff with their carts tending to resident rooms. Interview with staff revealed that dedicated housekeeping staff clean each resident’s room daily, including making their bed, tidying the room up, and taking trash. Care staff assist with cleaning resident rooms, as time allows. Weekly, a deep clean is done on each room, per their schedule. Deep cleans include washing and changing resident sheets, cleaning the bathroom, vacuuming, dusting, mopping the floors and anything else needed. LPA observed R1’s room to be neat and tidy with no housekeeping concerns. Based on interview and observation, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “staff do not clean resident room timely” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff do not put resident’s call button in a place accessible to resident:” LPA interviewed staff and residents related to the facility’s pull cord system and response time. The facility contains a pull cord system; each resident room has one cord in the bed area/living space of the room and a second pull cord in the resident bathroom. When a resident pulls the cord, a light illuminates outside the resident room and on a switch boards located at the front desk and in the medication room. Interview with staff revealed there are some residents who have a hard time locating their pull cords in the event of an emergency, particularly at night. The cords are long and when a resident has the cord on their bed and are restless at night, the cord may fall on the ground. When staff come by to check on a resident, staff stated they check to ensure the resident’s pull cord is in an easily accessible location. LPA observed the pull cords in both R1’s bedroom area and in R1’s bathroom. The cord in R1’s bedroom is long and was observed to be on R1’s bed at the time of LPA’s visit. The cord in the bathroom area is shorter, but was observed to be accessible while in the bathroom near the toilet area. Residents interviewed indicated sometimes their pull Report Continued on LIC 9099-C (p.4) cord falls down, but that staff have been helpful in attaching a longer cord or trying to put the cord in a place that it is less likely to fall. Based on interview and observation, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “staff do not put resident’s call button in a place accessible to resident” is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of the report was provided.