Complaint·April 12, 2023

briefs checked. Staff stated their job is to change residents’ briefs so that they are dry. Multiple staff stated many times residents would have soiled diapers full of feces that had dried already, indicating it had been a long time since they were changed. Staff indicated sometimes residents had feces on their back or in their pants due to not being changed often enough. Staff stated on one occasion, a resident had it on their hands, body, face, on the bed, on the floor, and stated it was “everywhere.” LPA observed a photograph labeled Room 224 showing a pair of jeans that are soiled with feces. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility staff did not keep the facility premises in clean and sanitary condition at all times. LPA interviewed staff, who stated staff on other shifts would not clean the facility areas and as a result the facility had a “bad smell.” Staff interviewed stated the floor, walls and toilets were dirty. LPA observed a photograph of a dirty floor in Room 223, showing brown spots on the floor. LPA observed a photograph of the toilet in Room 223, showing feces smeared on the toilet seat. Staff interviewed indicated resident’s rooms were dirty and dusty, the toilets were dirty with urine for multiple days, and the bathroom floor had spots of urine and was not cleaned timely. Staff interviewed indicated feces was also on the floor, and it would just be wiped and not deep cleaned. Responsible parties interviewed indicated resident rooms smelled of urine, the floor under resident beds was dirty and had trash, and the bathroom floor was dirty and sticky from urine. Responsible parties indicated they cleaned resident’s rooms on a few occasions due to the condition. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility staff did not keep centrally stored medication locked. It was alleged that a medication was found on the counter of Room 220. LPA was provided a photograph showing a clear plastic cup filled with a brown liquid. There is no scale to the photo, but the cup appears to be a clear plastic drinking glass of at least 8 ounces. LPA was unable to determine if the cup contained medication or not, but it does not appear to be medication. Staff interviewed stated medications were kept locked. Witness interviewed indicated they were not aware of the medications being unlocked around the time of this complaint. One staff stated sometimes the medication room door was unlocked. During today’s visit at approximately 11:39 am, LPA observed the unlocked medication cart was unattended in the common area near several residents who were participating in an activity. LPA observed two residents walking near the medication cart. At the time of LPA's observation, Staff 1 (S1) approached the medication cart. S1 stated “I could have sworn the medication cart was locked." Please continue to 9099-C, Pg 3. Based on the information obtained, the allegation is deemed Substantiated at this time. LPA recommends the Administrator remind all staff that the medications need to be locked at all times. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted. Deficiencies cited on 9099-D. Copy of report and appeal rights issued at the time of the visit.