Follow-up on corrections·February 12, 2024

Licensing Program Analyst (LPA) Hansen conducted an unannounced case management inspection, while delivering complaint findings, and met with General Manager Rabah Sbaitan. The purpose of this case management is to follow up on five self reported incident reports submitted to Community Care Licensing (CCL). Two on 12/22/2023 and one on 12/28/2023, 1/29/2024, 2/1/2024, & 2/8/2024. CCL received a self reported incident report reporting on 12/14/2023 night medication technician (Med-tech) notified nurse resident (R1) had frequent urination. Review of R1’s medication records revealed R1 had not received Tamsulosin medication since 11/26/2023 due to pharmacy unable to renew prescription as incorrect doctor was listed. Primary Care Physician’s (PCP) office notified, and emergency supplies of medication were delivered and given to R1 on 12/15/2023. LPA obtained additional information regarding a medication error that occurred on 12/14/2023 involving R2. On 12/13/23 delivery of Midodrine was assigned to Med Tech instead of nurse, which was given at 8 am, then another dose was given at 9:40am by nurse without checking Emar. R2 assessed with no adverse effects noted. All required parties notified. In-service training provided & LPA obtained copy. LPA followed up on an incident submitted to CCL on 1/16/2024 for a medication error that occurred on 12/28/2023. On 12/29/2023 AM Medication manager found cup with R3’s PM medications. Nurse assessed R3 with no adverse effects. LPA obtained internal investigation, disciplinary action, & In-service training. LPA is providing LIC 9102 TA for reporting incident to CCL later then Title 22 regulations of 7 days. CCL received a self reported incident report on 1/29/2024 of a medication error that occurred on 1/17/2024. R3 had received two 5mg tablets of their amlodipine instead of one as staff opened a new bubble pack of mediation prior to finishing the current supply. There were no adverse effects shown and all required parties notified. Continue on LIC809-C LPA obtained internal investigation, disciplinary action, & in-service training. On 2/8/2024 CCL received a self reported incident report regarding R4. On 1/29/2024 staff provided R4 2 doses of Levetiracetam 250mg at 9am instead of 1. R4’s Mediation records indicate 1 dose in AM & double the dose at 5pm, daily. It was revealed a new bubble pack was opened when the old one was not empty. R4 did not show any adverse effects. All required parties notified. LPA obtained staff records & in-service training. LPA is issuing a citation today for multiple medication errors and Civil Penalties for repeat violation in less then 12 months. CCL received a self reported incident report reporting on 1/30/2024 at approximately 5:40 pm R5 eloped from community. Staff and law enforcement conducted search. At approximately 6:15 pm R5 was escorted back to community by neighbors of area. Full assessment conducted of R5 with no signs of injury or pain noted. LPA obtained records indicating R5 has diagnosis of dementia and is not to leave community unassisted. LPA is issuing a citation today for R5 eloping from facility without staff knowledge on 1/30/2024 . General Manager has informed R5 just moved into facility end of January 2024. Wonder guard alarm had been placed on R5 and 1:1 had been implemented but after care meeting on 2/6/2024 R5 was moved to memory care unit. Citation issued during visit. ****Civil Penalties are being assessed in the amount of $250 due to a second repeat citation issued for the same section 87705(b)(2) Care of Persons with Dementia, in less than 12 months. Deficiency last cited on 4/11/2023. Citation issued during visit. ****Civil Penalties are being assessed in the amount of $250 due to a second repeat citation issued for the same section 87465(a)(5) Incidental Medical and Dental Care Services. in less than 12 months. Deficiency last cited on 6/15/2023. *******Total Civil Penalties being given today $500 Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided