Incident investigation·December 3, 2024

On 12/3/24, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to this facility to conduct a case management visit regarding an incident occurred on 11/22/24 that the facility self-reported. LPA met with the Administrator, Elena Cuevas (AD), and explained the purpose of the visit. On 11/22/2024, an incident occurred at the facility where all Memory Care (MC) residents did not receive their scheduled morning medications due to staffing issues. The absence of a qualified medication technician (med tech) to cover the morning shift in the MC section led to this oversight. The med tech scheduled for the morning shift called out sick, and despite efforts, no other qualified staff member was available to cover the shift. Although an additional med tech was contacted to report to duty later that day, they were unable to arrive until 11:00 AM, leaving a significant gap in medication administration. A med tech in the Assisted Living (AL) section was already occupied assisting AL residents with their own medications, and it was determined that they could not assist in the MC section due to the high demand of residents needing their medication in AL. The facility’s Administrator (AD) and Residential Care Coordinator, who were not trained in medication administration, were unable to step in and help. As a result, no medication was administered to the MC residents in the morning as scheduled. In compliance with safety protocols, the AD and Health and Wellness Director (HW) promptly notified all affected residents' responsible parties, hospices, and physicians of the incident. Per AD, residents' physicians instructed the staff to just monitor the residents and not give the morning medications. They closely monitored the affected residents for a 48-hour period for any potential adverse reactions, but fortunately, no negative effects were observed. Following the incident, the facility took immediate action to prevent a recurrence. AD and HW conducted an in-service training session for the med techs, focusing on proper medication management, communication, and responsibilities, as well as dementia care. {1 of 2} Additionally, the AD noted that the current Healthcare Director (HD) had been on leave and was unavailable to assist during the staffing shortage. As a result, the facility hired an interim Healthcare Director, additional Residential Care Coordinator, and three new med techs to ensure adequate staffing. A plan was also implemented to increase coverage in the AL section by adding a second med tech to the morning shift, who could be deployed to MC if necessary. The AD and HW also communicated with the residents and their families through a town hall meeting, where they discussed the facility’s corrective action plan. This plan included hiring an interim Resident Care Coordinator to serve as the Memory Care Director until further notice and appointing another Residential Care Coordinator to oversee MC and AL staff, ensuring proper support and compliance with care plans. A review of the staff schedule confirmed that, on the day of the incident, only one med tech was scheduled from 6:00 AM to 2:30 PM, highlighting the staffing challenges that contributed to the oversight. A review of the Medication Administration Record (MAR) confirmed that morning medications were not given to MC residents on 11/22/2024. Based on information gathered, the facility did not ensure that MC residents received their prescribed morning medications which was a result of unforeseen staffing issues. However, the facility took action by reporting the incident to the Department, notifying the necessary parties, monitoring residents for adverse effects, providing additional training to staff, and implementing a comprehensive plan to address future staffing shortages. As a result of this visit, the following deficiencies were cited on 809-D, per California Code of Regulations, Title 22. An exit was conducted, and a copy of the this report and appeal rights were provided. {2 of 2}