Incident investigation·December 9, 2025

Citations

4 citations recorded^*CCLD

• 87465(g)Type B

  CCR 87465 Incidental Medical and Dental Care(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with section above by not activating 9-1-1 if an injury or other circumstance which poses a potential health and safety risk to the persons in care.

• 87465(a)(6)Type B

  CCR 87465(a)(6) – Incidental Medical and Dental CareWhen requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.This requirement was not met as evidenced by: Based on record review and interviews, the licensee failed to ensure accurate medication administration documentation for R2. On 10/18/2024, the MAR reflected narcotic administration times of 6:00 a.m. and 2:00 p.m., while the Individual Resident Narcotic Record showed administration at 6:00 a.m. and 7:00 a.m. The discrepancy between the two documents demonstrates falsified or inaccurate medication administration documentation which poses a potential health and safety risk to the persons in care.

• 87629(b)(1)Type B

  CCR 87629(b)(1) InjectionsInjections. Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance.This requirement is not met as evidence by: Based on record review and staff interviews, the licensee did not comply with the section cited above by ensuring that injections are administered by an appropriately skilled professional. Records show that Medication Technicians (Med Techs), who are not appropriately skilled professionals, were administering insulin injections and performing blood glucose checks for R2. S1 confirmed that Med Techs “set up” insulin pens and used a “hand-over-hand” method during injection. This failure to ensure proper training and delegation in medication administration poses a potential health and safety risk to residents, including risk of injury, infection, or medication error.

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• 87622(a)(2)Type B

  Fecal Impaction Removal, Enemas, and/or Suppositories(a) The licensee shall be permitted to accept or retain a resident who requires manual fecal impaction removal, enemas, or use of suppositories under the following circumstances: (2) Manual fecal impaction removal, enemas, and/or suppositories shall be permitted if administered according to physician's orders by either the resident or an appropriately skilled professional.This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with section above by not following dr's orders with R1 self-administering their intravaginal cream or appropriately skilled professional will administer the medication which poses a potential health and safety risk to the persons in care.

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