Incident investigation·December 19, 2023

At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit. LPA met with Larona Farnum, toured the facility, reviewed records and interviewed staff. This visit is due to a report of medication bubble packs being tampered with. On 11/28/2023, medication technician on duty observed a difference in the feel of a medication. Upon further investigation, 9 other residents medication cards were discovered to be tampered with. In all cards, the medication Oxycodone 5mg, was replaced with Quetiapine. The pills are very similar in appearance. The cards appeared to have been separated and then resealed to prevent detection. Licensee notified law enforcement immediately as well as CCLD and the Ombudsman. Licensee has implemented additional checks to ensure medication received by the pharmacy is intact and the cards are checked at every change of shift. The incident is under investigation by the Humboldt County Sheriff's Department. LPA will follow up with facility upon completion of that investigation. While touring the facility, LPA observed the medication cart near the entrance to the dining room and the medication technician was nowhere in sight. LPA observed the cart was unsecured and there was a plastic baggy on top that contained medication. There were approximately 16 residents present. LPA alerted the medication technician and the cart was secured immediately. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Larona Farnum and Appeal rights were given.