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32 | The investigation revealed the following:
Allegation: Staff do not ensure resident’s toileting needs are being met
A family member stated that they found a urine sample and would find dirty diapers in R1’s dresser drawer. The family member has expressed concerns that the resident is not consistently receiving adequate assistance with diapering. Per interview on 7/28/26 with the Caregiver Supervisor S2, residents with incontinence care needs identified in their care plans are provided incontinence care and checked for changing at least every two hours, or more frequently as needed. S2 also stated that it is possible that R1 read the sign posted in her room stating, “Attention All Employees: Please do not dispose of soiled diapers in the bathroom trash cans.” Based on this, S2 believe the R1 may be changing their own pull-up and placing the soiled pull-up in the drawer instead of disposing of it appropriately. Per interviews with S1-S5 on 7/28/26, soiled diapers are disposed of in the trash bins.
LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 5(R1 – R5). Of those who interviewed 3 out of 5 denied the allegation. Two residents stated that they go to the bathroom on their own.
Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not ensure resident’s toileting needs are being met,” therefore, the allegation is unsubstantiated.
Allegation: Staff do not ensure residents rooms are clean and sanitary
It is being reported that a family member visited R1 and observed a sign in the bathroom for facility staff stating, “Please do not dispose of soiled diapers in the bathroom trashcans because families are complaining of the smell.” Per interview with S1 and S2 on 7/28/26, the caregivers carry disposable trash bags with them as the change the residents. Caregivers dispose of diapers in the trash bags and the trash bags are then taken to the big trash bins. On 7/28/26, LPA Shirley reviewed the House Keeping, Laundry and Janitors schedule for June 2026. The Housekeeping schedule begins at 6:30am thru 3pm, Monday thru Friday. On 7/28/26, the Maintenance Assistant stated that the schedule is the same for the weekends. Per interview on 7/28/26, S6 stated that all rooms are cleaned daily. On 7/28/26, LPA Shirley conducted a tour of this facility and went to R1’s room and observed that the room was clean.
Con'd on 9099-C
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