Complaint Investigation Report

On 02/28/2021, the facility completed R1’s level of care assessment due to a change of condition. According to R1’s level of care assessment, R1 needs assistance with grooming, bathing, dressing, eating, medications, and toileting. R1 is on hospice but does not require additional staff involvement. R1 requires a status check 4-6 times per day. House keeping is required daily (bed making or minor tidy up such as emptying trash). R1 also requires additional laundry 2 times weekly.

On 04/19/2022, LPA Keosavang toured the Memory Care Unit (the Villa) with Executive Director, Debra Duval. The facility has two (2) Memory Care Unit, and the Villa is a separate building which has a total of 12 residents’ bedrooms. LPA Keosavang observed a total of three (3) bedrooms in the Villa. During the tour, LPA observed R1’s bedroom has strong urine odor.

On 10/19/2022, LPA Keosavang conducted interviews and gathered statement from facility staff. Interview statement received from S1 indicated, R1 requires assistance with toileting and that R1 would try to independently use the toilet on his or her own. R1 would defecate and urinate on self. Facility care staff would assist R1 in changing into new clothes. After assisting R1 with change into clean clothes staff would remove filthy clothes from room and put them in the laundry room. Interview statement received from S2 indicated, there has been a time where staff did not change R1 during a shift change. S2 conducted rounds during start of shift and observed R1’s incontinence brief were soiled and have not been changed. S2 mentioned it to staff that was working on the earlier shift and offered to assist. S2 stated, R1 had many incidents where R1 would stand up and urinate on the floor. After assisting R1, filthy clothes may not have been put in the laundry room and washed immediately which may cause the strong urine odor in R1’s room.

Due to this information CCL finds the allegation to be SUBSTANTIATED . – A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited on the attached LIC 9099-D.

An exit interview was conducted, and a copy of the report left at the facility.