Complaint Investigation Report

Staff left residents in soiled diapers for an extended period of time. – SUBSTANTIATED

It was reported that staff leave the residents soiled diapers for hours.

LPA reviewed care plans for Resident 1 (R1) and Resident 2 (R2). Both residents are incontinent and require incontinence care as needed using peri care protocol. Staff instructed to monitor urine and stool, monitor pad. Keep skin dry, keep residents clean and comfortable. The care plans include a schedule of required toileting times per day.

LPA reviewed Recorded Care Reports for December 2025 and January 2025 for Resident 1 (R1) and Resident 2 (R2). The care reports show that staff did not record toileting care for ether resident during these months.

All staff stated that the residents were not left in soiled diapers.

It was determined since staff did not record that toileting care had or had not been completed for either resident there is no proof that the care was provided as outlined in the care plan. LPA is substantiating the allegation based on staff not being competent enough to keep accurate records on incontinent care.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to Executive Director Grace Hawkins.