Incident investigation·April 14, 2022

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to follow up on an incident report received on 04/13/2022. LPA met with Director of Resident Services Allan Macabitas and explained the reason for the visit. Incident report dated 04/06/2022 indicated Resident 1 (R1) had notified facility management that R2 was upset and having a psychiatric issue. Management responded and assessed resident to be calm and verbally responsive. Facility contacted R2's family member who responded and informed facility that resident had taken a large amount of Tramadol and wanted to end the resident's life. 911 was called and resident was transported to the hospital for an evaluation. Resident to be assessed upon return to facility and facility is arranging for home health psychiatric services as well as a care companion. Per physician report dated 08/30/2019, resident is diagnosed with Mild Cognitive Impairment and is unable to manage medications. The Tramadol had been in the resident's room. Pre-Appraisal dated 09/05/2019 indicates R2 is diagnosed with Bi-Polar Disease as well. Facility had been utilizing facility specific medication assessment dated 12/04/2021 and allowing resident to manage own medications. During the visit, LPA toured the facility as well as interviewed staff and witness. LPA observed R2's medications in the resident's room. Based on the observations made during today’s inspection the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.