Complaint Investigation Report

Staff allow a resident to be in soiled clothing for extended periods of time

At complaint intake on August 30, 2023, the RP reported that on multiple occasions the RP had visited R1 and found R1 to be soaked in urine. On March 4, 2024, LPM Fong spoke with the RP who reiterated that R1 was found to be soaked in urine on multiple occasions and that this was brought to the attention of S4. On March 5, 2024, LPM Fong conducted a continuing complaint visit and observed that R1s MD report and intake Appraisal indicated that R1 was independent in toileting. On that same date, LPM Fong interviewed S2, S3, and S4 – all of whom were confirmed to have been employed during the subject time period. S2 reported having no knowledge of the issue, however, S4 acknowledged that family reported coming to the facility to find R1 soaked in urine. An internal investigation was performed, and it was determined that R1 had been left in urine soaked garments and bed for an extended amount of time. Updated Needs and Services documents from August, 2023, indicated that R1 did require incontinence undergarments and changing. Therefore, the allegation is substantiated.

Staff do not properly maintain resident’s bedroom.

At complaint intake on August 30, 2023, the RP reported that during multiple visits, R1's room was found to have urine soaked clothing and bedding strewn about and with strong urine smell. On March 5, 2024, LPM Fong interviewed S2, S3, and S4 – each stated having no knowledge of R1s room not being properly maintained, cleaned, or serviced. On March 8, 2024, LPM Fong spoke with W1 (neutral witness) who reported having visited R1 at the facility mid-morning and found the room to smell strong of urine – to the point where W1 could not stay in the room. W1 also reported that the laundry basket was full of urine soaked items and that W1 pulled the basket out of the room and requested staff to remove and launder. Therefore, the allegation is substantiated.