Follow-up on corrections·February 15, 2024

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA Quiroz was greeted and granted entry into the facility by front desk receptionist and met with Melanie Washington, Executive Director and explained the reason for the visit. During the course of the investigation, the following deficiencies were observed and are being cited via this case management deficiency. Resident 1 (R1) was admitted to the facility on April 1, 2023. Per R1’s Physician report dated June 8, 2023 resident is not able to administer or store their own medication. On August 12, 2023, Staff 1 (S1) reported being busy finishing tasks before the end of their shift and passed off medication duty to another MedTech, Staff 2(S2), to finish distributing. S1 reported placing R1’s medication with Resident 2 (R2)’s, medication into white cups with their room numbers written on it. S1 signed off on both R1 and R2 taking their medications based off word of mouth from S2. S1 and S2 did not physically see residents take their medications. On the morning of August 13, 2023, R1 saw a white cup with medications on the nightstand and assumed they were for them and ingested them. When S1 came in to do R1’s morning medication disbursement, S1 found out S2 had left medications for R2 on R1’s dresser and didn’t distribute them like they had said they did the night before. Shortly after taking the wrong medications, R1 became lethargic and unresponsive and was transported to St. Jude Hospital and returned to the facility later that night. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report, 809-D Page, and appeal rights was left at the facility.