Complaint·December 5, 2021

Regarding the allegation: Staff are mishandling medication It was alleged that medication errors were happening, primarily on weekends. During today’s visit, interviews revealed that on 11/28/2021, there was a medication error in the Memory Care Unit, where approximately twenty-eight (28) residents did not receive their 5:00 p.m. dosage of medication due to an alleged mis-communication. However, the medication logs were signed off, indicating that all residents had been assisted with receiving their medication. Records review demonstrated that the Executive Director reported this incident to LPA Kassandra Lopez on 12/01/2021. Interviews revealed that the residents’ primary care physician had been notified and residents were monitored for any adverse reactions. Based on the information obtained, there is sufficient evidence to support the claim that staff mismanaged medication. This allegation is deemed Substantiated at this time. Regarding the allegation: Failure to report unusual incidents It was alleged that incidents were transpiring in the community, yet they were not being reported to Community Care Licensing. An interview revealed that whereas staff observing unexplained bruising on residents, staff admitted to not submitting unusual incident reports to Community Care Licensing. A review of internal facility documents revealed that Resident #1 was observed with unexplained bruising on 01/27/2021, 03/08/2021, and 03/14/2021. Resident #2 was hospitalized on 11/22/2020. Resident #3 had unexplained bruising and/or a skin tear on 1/06/2021, 2/15/2021, and 03/08/2021. There were no submitted incident reports for the above-mentioned occurrences. Lastly, a file review revealed that the community did not submit incident reports from May 2021 – the end of October 2021, with the exception of one report submitted in August 2021. Based on the information obtained, there is sufficient evidence to support the claim that the facility failed to report unusual incidents. This allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted, today's reports and appeal rights were reviewed and issued.