It is alleged that the facility did not clean soiled adult diapers containing urine under residents’ bed and by the wall. It is further alleged that the facility did not discard a tube of cream with feces stored in R1’s drawer.

During staff interviews, Staff stated that resident rooms are checked and cleaned daily. Staff reported that caregivers are responsible for providing morning care, including changing residents, disposing of soiled diapers, and picking up trash observed during care. Housekeeping reported they clean resident rooms and bathrooms after morning care and complete additional cleaning as needed throughout the day. Staff acknowledged that some residents, including R1, frequently discard trash and soiled items on the floor or under beds. Staff stated that these items are addressed when observed or reported. Staff reported that caregivers and housekeeping work together to maintain cleanliness and denied that resident rooms are left unclean. Regarding the incident involving diapers found under R1’s bed, S1 stated the housekeeper assigned that day had just arrived and was unaware of the diapers. S1 reported the issue was discussed with the family, and staff responsibilities were reiterated. S1 denied observing neglect related to room cleanliness and stated that staff routinely follow up to clean resident rooms and remove trash.

During R1 interview, R1 stated they are doing well and that everything is okay. R1 reported no complaints. During resident interviews R2-R4, residents R2–R4 reported they were doing well overall. R3 stated they are doing well; reported no complaints regarding the cleanliness of their room. R3 further stated they use plastic bed mats to step on because the floor is often cold, which is why LPA observed a plastic mat under their bed. R5–R7 had cognitive challenges and were unable to understand LPA’s questions.

(continued on 9099C)

It is alleged that staff do not consistently ensure toilet paper is available in R1’s bathroom.

During staff interviews, Staff stated that toilet paper is routinely stocked in resident bathrooms. Staff reported that housekeeping is primarily responsible for checking and refilling toilet paper in resident bathrooms during daily cleaning. Caregivers stated they also replace or add toilet paper as needed when they observe supplies are low or when residents request additional toilet paper.

During the complaint visit, LPA observed resident bathrooms to be stocked with toilet paper. Toilet paper rolls were observed present in resident bathrooms at the time of observation. No residents were observed without access to toilet paper, and no complaints regarding lack of toilet paper were reported to LPA during the visit.

Allegation: Staff failed to provide adequate supervision to resident in care resulting in multiple falls.

It is alleged that staff did not provide adequate supervision to the resident in care, resulting in resident falls.

During staff interviews, staff stated that residents are supervised at all times. Staff reported that R1 walks independently using a walker and does not typically request assistance. Staff stated that R1 is permitted to walk independently, including outside in enclosed patio area which is consistent with his assessed needs.

(continued on 9099C)

During R1 interview, R1 reported no concerns in regard to supervision. During resident’s interviews R2-R4, residents did not report any concerns regarding to supervision. R5–R7 had cognitive challenges and were unable to understand LPA’s questions.

During the complaint visit, LPA observed that the facility had outdoor cameras in place to monitor residents while in the patio area. The camera monitor was in the administrator’s office, and LPA observed the system to be operational at the time of the visit. LPA observed caregivers attending to residents and providing supervision during the visit.

Based on the investigation conducted, which included interviews with staff and residents, as well as a review of relevant records, there was insufficient evidence to support the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided.