Incident investigation·December 20, 2021

On 12/20/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced at the above facility to conduct a Case Management visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Kelly Metz and Resident Services Director, Barbara Robinson The purpose of today’s visit is to follow up on an incident report that was submitted to the Fresno CCL office on 11/30/2021. It was reported that on 11/20/2021 at approximately 8:00PM, R1 was given the wrong dose of Oxycodone. Physician order indicates that R1 should receive one 5mg tablet of Oxycodone by mouth at bed time. On the date indicated above, R1 was given two 5mg tablets equaling 10mg. Facility staff notified physician and responsible party. On 03/30/2021 and 05/07/2021, LPA Walton conducted Case Management visits to follow up on reports that facility did not administer medication as prescribed. The facility was issued a citation on both dates based on California Code of Regulations Section 87465(a)(5). Based on interviews and record review, a deficiency is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87465(a)(5) on the attached 809D. A Civil Penalty is being assessed in the amount of $1,000 for a repeat violation in accordance with California Code of Regulations, Title 22. An exit interview was conducted and a Plan of Correction was reviewed and developed with Administrator. As a COVID-19 precautionary measure, a copy of this report and appeal rights were provided via email and an electronic read receipt confirms receiving these documents. Report signed on-site by facility representative.