Incident investigation·January 2, 2024

At approximately 9:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to several incident reports submitted to CCL ranging from October thru December 2023. LPA met with Executive Director Paul Oseso, reviewed records and interviewed staff. Incident 1: On 10/05/2023, staff observed the same medication, Quetiapine 25mg, was entered into their computer system twice, thus R1 was being given the medication twice daily instead of only once a day from 09/26-10/04/2023. An investigation was conducted and found that one nurse had entered the medication into the system manually. The normal procedure is to not enter medications manually. The medication orders are sent to the pharmacy, which updates the system. Retraining was conducted for nurses on the process of confirming medications in their system. Retraining was conducted on how to handle and report medication incidents. Incident 2: CCLD received a self reported SOC341, Report of Suspected Dependent Adult/Elder Abuse, on 10/11/2023. The report described an incident between two residents. Staff heard an altercation in the hallway and observed resident, R2, push resident, R3, to the ground and kick them. Staff separated residents and assessed them for injury. LPA reviewed resident care plans and found notes regarding resident behaviors and how staff should react. Training has been conducted on combative behaviors and how to report incidents. Staff followed their procedures and there were no injuries to resident. Incident 3: On 12/27/2023, CCLD received an incident report regarding a resident that did not receive 2 of 6 daily applications of a medication from 12/11-23/2023. The medication order was put into the system to administer the medication during the night time hours, but the medication technician was not informed. Physician was notified and the dosing schedule was updated. Continued on LIC 809-C... Training has been conducted to address communication between nurses and medication technicians. ***This is a repeated violation of the same regulation section in a 12 month period. An immediate civil penalty is being issued in the amount of $250.*** 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 Paul Oseso and Appeal rights were given.