Incident investigation·August 21, 2024

At approximately 8:05AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to several Unusual incident reports submitted by the facility. LPA met with Executive Director Roger Endert and reviewed records. LPA received two (2) reports that a medication error had occurred, and two (2) reports of residents leaving the facility without staff assistance. On 07/31/2024, staff noticed there were two different orders for the same medication and resident, R1, had received both. Facility notified responsible party, physician and pharmacy to correct the error. R1 was monitored for side effects due to the error and none were observed. On 08/11/2024, resident, R2, was given the wrong medication at the wrong times twice, once in the morning and at noon. Facility notified responsible party, physician and pharmacy to correct the error. R2 was monitored for side effects due to the error. R2 stated they were a little dizzy but was fine a short time later. ***This is the third violation in a 12 month period. An immediate civil penalty is being issued in the amount of $1000 for repeating the same code section in a 12 month period.*** On 06/22/2024, staff observed resident, R3, wandering around in the parking lot of the facility. Staff were able to redirect R3 back into the facility with no further incidents. Staff checked the doors and alarms and initiated more frequent checks for the resident. On 08/12/2024, staff was returning from their break and observed a resident, R4, across the street from the facility. Staff was able to assist the resident back to the facility. Facility has updated resident care plan to address this behavior. 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.