Complaint Investigation Report

Over six (6) visits LPA observed Memory Care hallways and public areas to be clean, however, during tour of R1’s room LPA observed bed to be made over dirty clothing and used tissues. Interviews with RP indicated at least six (6) documented instances over the course of two months of R1’s bedding not being laundered, despite being soiled, and dirty clothes being reused without laundering.

Staff are not meeting resident's hygiene needs – RP alleges that facility staff are not bathing R1 regularly resulting in multiple instances of R1 going one (1) or more weeks without bathing. Interviews with staff indicated that residents will not often refuse bathing, but mood changes may cause them to refuse. Further interviews indicated that if R1 is not bathed on time they will refuse bathing for the rest of the day. Review of facility Shower Refusal form indicated that upon a resident refusing a shower, the form shall be signed by a caregiver, an LVN/medtech, and a date shower moved to, and that “shower must be moved to the next day if there is a refusal”. Review of Shower Refusals for R1 indicated approximately seventeen (17) instances of showers being refused over the course of approximately five (5) months. Further review of Shower Refusals indicated four (4) of seventeen (17) were signed off by an LVN/medtech, and zero (0) of seventeen (17) had a date moved to. Review of resident care notes indicated showers were documented, however, when compared to Shower Refusals R1 is not being documented as being showered the day following a refusal and will not be showered at least until their next scheduled shower day without further refusal forms. Further review of R1 care notes indicated R1 has gone twenty (20) or more days without being showered. Interview with RP indicated multiple instances of R1 not receiving scheduled showers despite requesting them.

Based upon evidence gathered, there is a preponderance of evidence to prove that the allegation has been SUBSTANTIATED and is v alid .

Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC9099D.

Exit interview conducted with Administrator, whose signature on form confirms receipt.