Follow-up·January 17, 2024

On 01/17/2024 at 9:40AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a case management visit in regards to an incident report received on 11/17/2023 and SOC341's received 11/29/2023 and 12/11/2023 . LPA met with Resident Care Coordinator (RCC), Jetrey Inarda and explained the purpose of the visit. Director of Social Services, Olga Leynov and Quality and Compliance Nurse, Janelle Jones also attended visit. Based on the incident report received on 11/17/2023, resident (R1) was given the incorrect medications. Facility notified medical doctor (MD) and R1’s responsible party (RP). R1 was monitored for ill effects but none were noted. Med tech received additional training to avoid medication errors. During visit, LPA reviewed R1's file including physicians report, care notes, and incident report . LPA spoke with RCC and was informed that the medication mix up was a result of S1 picking up a bowl of soup that contained R3s medication. S1 then gave the soup to R1. It is confirmed that the medication in the soup was R3's bowel regiment medication. LPA was informed that S1 received 8hr medication training, a write up, and shadowing. The facility also implemented a labeling system for residents food, facility wide competency training's for med-techs, and that quality compliance nurse now comes to do training's and audits four times a month. LPA also toured the facility kitchen areas to ensure proper labeling of food. As a result of this incident LPA administered a Technical Violation. Report continues on LIC 809-C Based on the SOC341 received on 11/29/2023 on 11/28/2023 S2 was heard yelling at R2. S3 reported hearing S2 yell something along the lines of "You are always yelling and wanting to be prioritized but I am busy too and have to feed other people." to R2. It was reported that R2 requested that S2 change her pants because R2 had dropped tooth paste on them. S2 inittially did not change R2 and scrubbed her pants with water to get out the stain. R2 stated that, "(S2) wanted their way and I wanted my way, but eventually S2 did change my pants" During visit LPA intervied R2 and found that they are happy and satisfied with the facility . LPA also reviewed Facility 5 day investigation conclusion and it states that S2 no longer works with and monitors R2 and has been reassigned. S2 also received the following training's: "Respect & Dignity; Resident's Rights; Elder Abuse; Communications with patients, residents and clients. R2 has had no ill effects of this incident and no psychosocial disturbances. LPA went over the importance of residents rights and effective communication. Based on SOC341 received 12/11/2023 R4 choked a visitor. Care staff then redirected R4. R4 attempted to enter another residents room when their visitor tried to stop R4, R4 proceeded to choke them. During visit LPA reviewed R4's care plan and found that R4 did not require a one on one and has since passed away. R4 was on hospice and was diagnosed with Dementia among other diagnoses. Visitor was also informed that for any future interactions to notify staff instead of interacting with residents directly. Exit interview conducted. A copy of this report provided.