complaint·March 28, 2025

...continued from LIC9099. Staff allowed a resident to be soiled while in care W2 reported he/she arrived at the facility for his/her shift t and found R1 was left in soiled clothing and sheets with feces. W2 report the incident to W1. W2 stated he/she saw S5, and S6 that morning and was not sure why no one had responded to R1. W2 stated all the caregivers or housekeeping would have had to do is put R1 in the shower. It was about 9:00 AM when S10 was passing the medications. It took S10 about 3 hours to comeback regarding R1’s ingrown toenails. W2 asked S10 to please give R1 the Imodium A-D for diarrhea; R1 was having stomach issues. W2 stated. “The one thing that is wrong with the facility for sure is that there are no nurses.” S4 was not at the facility that day. According to W2, S10 finally called someone, and it was about 1:00 – 2:00 PM before R1 received the medication to relieve the diarrhea. LPA interviewed W3, and W4, and both stated that they have had incontinence concerns with the facility also. Staff mishandled a resident's medication while in care Records requested and interviews with W1 and W2 revealed that R1 is prescribed Imodium A-D. The Medication Sheet has two separate and different entries for R1’s Centrally Stored Medication; neither were notated as being administered for 12/2024. LPA reviewed R1’s Physician’s Report (LIC602); LPA reviewed R1’s Progress Notes and there was not any notation or refusal for the month 12/2024. Interviews with W1 and W2 reveal that R1 had an incident with diarrhea and vomiting on or around 12/16/24. S10 administered Imodium (A-D); however, the time, date and dosage is unknown and was not recorded on any day of R1's Medication Sheet for the month 12/2024. Based on LPA’s observations, interviews and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED . Deficiency is cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and a copy of this report provided to Justin Zackzewski, Director of Hospitality.