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32 | (Continued from LIC9099)
Regarding the allegation that Resident #1(R1) was left soiled for an extended period of time. More specifically in October 2025 R1 was left in a recliner for 5–6 hours in urine and feces and had to call 911. Department interview with R1 revealed conflicting statements regarding the timeline of events and the level of staff intervention. R1 consistently reported there was a malfunction with the electronic recliner chair used for sitting and sleeping due to mobility limitations. Staff interviews, facility call light logs, and facility records all show multiple staff responses and attempts during the reported timeframe to address R1 concerns and personal care needs while in their malfunctioning recliner. Documentation reviewed did not support a period of several hours without staff contact or assistance. Further staff interviews reveal R1 did not require incontinent care and did not have a pattern of toileting accidents.
Regarding the allegations that staff are not properly bathing a resident in care and that staff are charging a resident for services not rendered. More specifically, the reporting party stated that staff are not bathing R1 properly, including not cleaning behind R1’s knees as needed, and that R1 is being charged for Level 2 care without receiving the corresponding services. Outside source interviews revealed that a caregiver assisted the resident with bathing and daily tasks when requested, although the resident had expressed dissatisfaction with staff assistance. Records review showed that the Needs & Services Plans documented bathing assistance, skin care monitoring, mobility assistance, escorting, and supervision as part of the assessed care. The plans assessed toileting as independent or minimal assist, and incontinence care or brief changes were not identified as required services. A comparison of the Needs & Services Plan with facility billing showed that Level of Care services corresponded with the resident’s assessed needs. Review of personal care documentation reflected repeated attempts by staff to provide bathing and skin care assistance. Review of call light logs for the period surrounding the reported timeframe showed consistent staff response with no prolonged gaps or periods of nonresponse. Facility notes did not document any episodes of soiling, incontinence, or delayed toileting. LPA observations revealed no indicators that the resident required incontinence care or brief changes, and personal care tasks documented by staff aligned with the services listed in the resident’s care plan.
Based on interviews, direct LPA observations, records review and interviews, a preponderance of evidence does not exist to prove that the alleged violations occurred. Therefore, the combined allegations are UNSUBSTANTIATED.
An exit interview was conducted with Executive Director Karinna Topete, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. |