Incident investigation·August 12, 2025

Licensing Program Analyst (LPA) Vincent Moleski and Regional Manager (RM) Stephenie Doub arrived unannounced to conduct a case management visit. LPA Moleski and RM Doub met with facility administrator Jennell Revera and explained the purpose of the visit. LPA Moleski reviewed an incident report received by the Community Care Licensing Division (CCLD) on July 28, 2025. The incident report stated that a resident (R1) was taken to a medical appointment on July 22, 2025. R1 had been experiencing "scant bleeding and foul odor when urinating." The physician reported that five medication-releasing intravaginal rings were removed from the resident's vagina during the visit. LPA Moleski and RM Doub reviewed a signed order from R1's physician dated April 7, 2023. R1 was ordered to have a new ring inserted every 90 days. The manufacturer of the intravaginal ring indicates on their product webpage that the devices should be removed after 90 days of use. Revera said there was no documentation to suggest that staff nurses were given initial training on the use of the devices. Staff nurses had been inserting the devices since July 2024, according to R1's medication administration records (MARs). LPA Moleski reviewed R1's MARs and observed that R1 was given four intravaginal rings by facility staff and one by skilled nursing staff between July 2024 and June 2025. Staff were trained on the use of intravaginal rings on July 24, 2025, after R1 had been seen by her physician. The training material included instructions from the manufacturer of the ring, which specify that the rings should be removed after 90 days. This facility is hereby cited per 22 CCR Sections 87465(a)(4) and 87411(d). Because this deficiency resulted in a resident's injury and/or illness, an immediate civil penalty of $500 is hereby assessed. Appeal rights and a copy of this report were left with Revera.