Incident investigation·September 21, 2021

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident reports submitted to Community Care Licensing. LPA was greeted and granted entry into the facility by Resident Services Director Irma Arreola and Executive Director Jeremiah Goodwin and explained the reason for the visit. Incident report dated 08/20/2021 indicated facility did not administer Resident 1's (R1) Fentanyl patch as directed. R1 had an order for Fentanyl patch 12mcg, routine every 72 hours, dated 08/18/2021. The medication was not started until family brought it to the facility's attention. Physician as well as hospice notified with no adverse effects noted. Facility received a subsequent order for Fentanyl patch with a start date of 08/20/2021 which was administered. Staff 1 was verbally counseled but did not receive a written warning. S1 has current medication training in the file. Incident report dated 09/05/2021 indicated Resident 2 was found on the ground in the parking lot outside facility entrance. 911 was called and R2 was transferred to Mission Hospital with bleeding and scrapes to knees. Per physician report dated 03/26/2021, R2 is able to leave the facility unattended and still drives a car. Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.