Incident investigation·April 27, 2023

At approximately 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to an SOC 341 form submitted to CCL on 03/22/2023. LPA met with Executive Director Kim Humphrey and reviewed records. The incident involved a resident having an emotional outburst and assaulting a staff member. LPA reviewed resident care plan and found plan to be updated and notes on communications with responsible person to address behaviors. During this visit, LPA was informed of a recent incident regarding a staff member observing bruises on the arms of R1. An investigation was conducted and notifications were made to Law Enforcement and the Ombudsman's office regarding the alleged abuse. The investigation did not find evidence of physical abuse but did uncover several medication errors made by staff. This is a summary of the investigation: During the morning medication time on 04/22/2023, 5 of 19 residents refused their medications. The medication technician, S1, made the proper notifications to the physician and responsible party and noted the medications were refused on the medication administration record, MAR. When the afternoon medication technician, S2, came on shift at 2:30PM, they told S1 they were going to give the missed medications to the residents. S2 took the missed medications from S1 and came back a short time later saying that the residents had taken their medications. S2 did not update the MAR or make any notifications. This action was in violation to physician orders and possibly could have done harm to residents. The 5 residents were observed closely for any side effects. 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 Kim Humphrey and Appeal rights were given.