Incident investigation·February 29, 2024

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit to follow up on an incident report received by Community Care Licensing on 2/27/2024. LPA met with Executive Director (ED) Kat Farris and explained the reason for the visit. Incident report indicated that on 2/24/2024 Resident 1 (R1) missed a dose of medication. Medication had originally been ordered on 2/20/2023. During interviews, Director of Wellness (DW) Lida Spicer stated medication dose was missed due to medication not being delivered by the pharmacy. DW and ED denied having any additional related incidents. During today’s visit, LPA obtained copies and reviewed pertinent documentation including R1's centrally stored medication record, R1's Medication Administration Record (MAR) for February 2024, medication request dated 2/17/24, and emergency request sent by facility Licensing Vocational Nurse (LVN) on 2/24/24. Per R1's centrally stored medication record, medication dose which was missed is of one capsule to be taken routinely by mouth before breakfast. Per medication request record, medication was requested on 2/17/24 to be approved on 2/20/24. Per R1's MAR, medication was missed on 2/24/24 and 2/25/24. LPA was provided with proof of emergency request submitted by LVN on 2/24/24. Medication was refilled the evening of 2/25/24 and R1 resumed medication on 2/26/24. R1's MAR indicated medication has been taken routinely since 2/26/24 and no further action is required. Based on observations made during today's inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview conducted, and a copy of this report was left at the facility.