Incident investigation·February 13, 2024

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Case Management – Incident visit to the facility. LPA met with Omar Garcia, Program Administrator. The purpose of today’s visit is to address eight (8) self-reported incidents reported to CCL on 5/18/2023, 5/19/2023, 6/21/2023, 8/7/2023, and 2/5/2024. Incident #1: On 5/18/2023, CCL received an incident report stating on 5/14/2023, Resident 1 (R1) was not administered a prescribed dosage of SM Enema (suppository) 3x week due to no staff nurse being on duty to administer the dosage. Due to the dosage being a suppository, the enema must be administered by a nurse. Incident #2: On 5/19/2023, CCL received a revised incident report stating on 5/15/2023, it was discovered that on 5/14/2023 at 8:00 AM, Staff 1 (S1) administered Vitamin B-12 to Resident 2 (R2) in error. LPA obtained a copy of the Physician’s medication order which states, “Take one tablet by mouth every other day.” The vitamin was not to be administered on this day (5/14/2023), as it was an "off" day for the medication. During today’s visit, Program Administrator Omar Garcia stated S2 was responsible for the medication error. LPA obtained a copy of R2’s Medication Administration Record (MAR) which indicates R2 received one tablet of Vitamin B-12 on 5/13/2023, 5/14/2023, and 5/15/2023. Incident #3: On 6/21/2023, CCL received an incident report stating on 6/19/2023, Resident 3 (R3) was not administered Lisinopril 40mg at 8:00 am on 6/19/2023 due to the medication had not been refilled. During today’s visit, Program Administrator Garcia stated the procedure to refill medications has been revised and is done weekly for the upcoming week. Program Administrator further stated an inventory is conducted once a week to include expired medications, low inventory medications, and prescription refills. Incident #4: On 8/7/2023, CCL received three incident reports stating on 8/4/2023 Staff 3 (S3) failed to administer medications to three clients. Resident 4 (R4) was not administered Lacosamide 200mg @ 8:00 am. Resident 5 (R5) was not administered Lorazepam 1mg (1 tab) @ 8:00 am and 1 mg (2 tabs) at Please continue to 809-C, Pg 2. 12:00 noon. Resident 6 (R6) was not administered CBD 20/mg/THC @ 8:00 am. LPA reviewed incident report which stated S3 did not follow facility protocol of having second medication check and stated not administering the medications as prescribed was "an over-sight". Incident #5: On 2/5/2024, CCLD received two incident reports stating on 2/1/2024 Staff 4 (S4) left their shift early without notice to other staff on duty. S4 was assigned to pass 8:00 pm meds but left it to Staff 5 (S5) to pass out the medications. Incident report states S5 was confused on whether Resident 6 (R6) and Resident 7 (R7) received their meds as the bubble packs were not labeled with dates. Incident report states the following day, S5 realized the 8:00 pm Atrovastatin 20mg was not passed to R6 and R7. Incident report states S5 notified Staff 6 (S6) who instructed S5 to continue dose as prescribed. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were cited during the visit. (See 809-D) Exit Interview Conducted. A copy of this report, Appeal Rights, and Civil Penalty issued at the time of the visit.