Incident investigation·September 6, 2024

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced case management visit to issue deficiencies discovered after reviewing incident reports. LPA met with Tyler Barnes, Administrator and explained the purpose of the visit. During the investigation, LPA Kontilis reviewed relevant documents and interviewed staff. LPA reviewed an incident report (IR) received 07/17/2024 that stated on 07/15/2024, Staff 1 (S1) failed to provide Resident 1 (R1) Morphine SO4 15mg tablet. R1’s physician was contacted on 07/17/2024 and R1 was placed on alert charting for 48 hours. The IR states med techs were provided medication training as a result of the medication error. An IR received on 07/19/2024 states on 06/30/2024, Staff 2 (S2) failed to provide medication to eleven residents in care. LPA requested physician’s orders for medications, Medication Administration Records (MARs) and staff schedules for June and July 2024. On 07/23/2024, LPA received a revised IR which provided additional information. The following medication errors were noted for 06/30/2024: -R2 did not receive their 8:00 pm: Senna 8.6 mg and Melatonin 5mg -R3 did not receive their 8:00 pm: Donepezil HCL 10mg and Mirtazapine 7.5mg -R4 did not receive their 5:00 pm: Biotrue Hydration Boost Eye Drops, Senna 8.6mg, Cephalexin 500mg -R5 did not receive their 8:00 pm: Ketorolac Tromethamine 0.5% Eye Drops, Timolol Maleate 0.5% Eye Drops, Quetiapine 25mg, Venlafaxine HCL ER 75mg -R6 did not receive 8:00 pm: Donepezil 10mg; Atorvastatin Calcium 20mg -R7 did not receive their 5:00 pm: Calcium 600-VitD3 600mg; 8:00 pm: Montelukast Sodium 10mg; Sertraline HCL 100mg; Donepezil HCL 5mg -R8 did not receive their 8:00 pm: Lorazepam 0.5mg, Quetiapine 25mg, Polyethylene Glycol 17mg -R9 did not receive their 5:00 pm: Memantine HCL 10mg, Acetaminophen 325mg, Preservision AREDS 250-90-40, Vitamin C 1,000mg; 8:00 pm: Donepezil 10mg, Melatonin 5mg Please continue to 809-C, Pg 2. -R10 did not receive their 5:00 pm: Aspirin 81mg, Atorvastatin Calcium 40mg -R11 did not receive their 5:00 pm: Flecainide Acetate 100mg, Atorvastatin Calcium 20mg, Triamcinolone Acetonide 0.1% cream -R12 did not receive their 5:00 pm: Hydrocodone 5mg, Famotidine 20mg; 5:30 pm: Senna 8.6mg; 8:00 pm: Trazadone HCL 50mg The incident reports indicate resident’s physicians were contacted on 07/17/2024, after the discrepancies were discovered. Additionally, all affected residents were placed on alert charting for 48 hours after the discovery. The IR states S2 was terminated from the facility, and other med techs were to receive ongoing training to review policies and procedures for medications. LPA discussed the importance of accurate assistance with medication with the new Administrator. Additionally, on 08/28/2024, 08/29/2024, and 9/5/2024, LPA reviewed three incident reports for R13 that indicated R13 had multiple private caregivers. The private caregivers had fingerprint clearance but were not associated to the facility. Additionally, record review and interviews conducted revealed the facility contracts with an outside home health agency for additional staffing when needed as well as 1:1 for private care. Records reviewed revealed 10 temporary staff members had fingerprint clearance but were not associated to the facility. The following deficiencies were observed (See LIC 809-D.) and cited from the CA Code of Regulations, Title 22 Regulations. Civil penalty assessed for criminal record clearance transfer violation. Exit interview conducted. A copy of the report and civil penalties was issued at the time of the visit along with appeal rights.