Complaint Investigation Report

Staff interviews revealed that staff incontinence care (including disinfecting and odor removal) is procedural and adaptive based on the needs of the resident. Staff 1 (S1) stated that with regards to R1, the conjunction of R1 refusing to bathe with the incontinence care that needed to be provided was adding to the malodorous smell of the room. Staff 3 (S3) stated the incontinence care routine for residents including checking them every 2 hours as needed, removing linens and soiled clothes from the room, and disinfecting the room to ensure cleanliness. Staff demonstrated knowledge of the proper procedures with incontinence care.

LPA Observations revealed that on the initial visit to open the complaint investigation, the room in which R1 resides was malodorous. The LPA observed the room to have a strong ammonia like smell and the LPA had difficulty staying in the room for extended periods of time. The LPA visited the same room that R1 was staying in on a subsequent visit one week later and the room was markedly improved. The smell was greatly reduced and the LPA could stay in the room for extended periods of time.

Based on relevant interviews and observations the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the ED.