Follow-up·November 24, 2021

Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced case management visit to the facility. LPA met with Administrator Elina Moilanen and stated the purpose of the visit. The purpose of the case management visit is to respond an incident report that was submitted to CCL Office incident occurred on 06/07/2021 regarding Resident (R3) going absent without leave (AWOL). Facility staff responded immediately once the facility alarm went off. Staff checked all residents and rooms. Facility staff found R3 at Pizza Hut. R3's Power of Attorney decided to move the R3. LPA followed up with incident report that occurred on 07/19/2021 and 07/27/2021 regarding medication errors for Resident (R1) and R2. On 07/19/2021, Staff (S1) provided R1 one tablet of Risperidone 0.5 mg, instead of ½ tablet. On 07/27/2021, S2 provided R2 with her medication Fentanyl 25mch/hr patch a day earlier. Per incident reports and Administrator, residents did not have adverse reaction and their primary physicians were notified. Residents were monitored by facility staff. Administrator reported S1 transitioned to another facility position and is no longer a medication technician. Administrator reported S2 quit on 9/9/2021. Due to the medication errors Administrator facilitated a all medication technician training on 10/21/2021. LPA followed up with incident report that occurred on 08/05/2021 regarding Staff (S3) and S4 were using hoyer lift. Facility will provide training to all caregivers on 12/8/2021 at 1:30p.m. Deficiencies are cited in LIC809D. Exit interview was conducted. A copy of this report, LIC809, LIC809-D and appeal rights were provided. The Licensee’s signature on this form acknowledges receipt of these documents.