Incident investigation·January 2, 2025

On January 02, 2025, at 10:40 AM Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to conduct a Case Management – Incident visit regarding (3) separate incidents that occurred on 12/23/2024, 12/22/2024, and 11/27/2024. Upon arrival, the LPA was greeted by the Executive Director (ED), Flavio Silva. The LPA disclosed the purpose of the inspection. 1) For incident #1, happened on 12/23/2024, resident (R1) was given wrong medication and resident (R2) was not given medication. On 01/02/2025, LPA Jain interviewed residents (R1 and R2), two staff members Executive Director (ED) and Resident Services Director (RSD). LPA Jain interviewed R1. R1 stated on 12/23/2024 morning, a nurse came to their room, didn’t turn on the lights, and gave the medication to R1. R1 ate the medication. R1 stated that their regular nurse (S1) came back after some time with medication again. R1 told the nurse they already ate it. The nurse told R1 nothing is marked on the computer and went out of the room. R1 picked the empty cup from the garbage and saw #241 written on it, which was not R1’s room number and went to ED’s office and told ED what happened. ED told R1 that they would investigate. R1 further stated that the nurse who gave the medication to R1 didn’t mark the medication given to R1 and luckily the medications were same and R1 didn’t feel any side effects of the medication given. R1 told their family members about this incident. LPA Jain interviewed R2. R2 stated that they have no idea if medication was not given to them on 12/23/2024 morning. R2 said nothing happened and its fine if they missed the medication. LPA Jain interviewed ED. ED stated that Incident happened on 12/23/2024 morning. RSD was working as med tech during the overnight shift from 12/22/2024 8:30 PM to 12/23/2024 7:30 AM. On 12/23/2024, around 9:40 AM, R1 came to ED’s room and said they took the medicine from room #241 while holding the cup. Continued on LIC809-C R1 stated to ED a different MedTech came in the morning and gave them the medication from this cup. R1 stated to ED when they got up around 7 AM, they didn’t recognize the med tech and went to garbage to pick up the medicine cup. The cup said room #241 and not room #229. ED asked R1 to stay in their office and asked R1 if they were doing OK. ED checked MARS to noticed both the resident’s medications were given. ED noticed the medication were the same but with different strength. ED asked the caregivers to monitor resident for any change of condition. ED asked MedTech to send a note to the R1’s doctor stating which medication were given to the resident. ED stated that resident (R2) never got their medication. Shift changed at 7 AM. RSD told med tech that R2 needs their medication. Med tech saw a cup in medical cart with room #229 (R1’s) medication inside. Med tech didn’t not give those medications to R2. ED contacted the family of R2 and told them that R2 missed the medication as Med tech didn’t give them medication to the resident. A note was sent to R2’s doctor on the missed medications. ED stated that staff member S1 is on vacation and will be back on 01/26/2025. LPA Jain interviewed RSD. RSD stated they started med pass around 5 AM on 12/23/2024. They were multitasking, while preparing medicines for the resident (R2), they were answering (2) phone calls and in between had to pause med pass to open the front door of the facility. When they came back to R2’s room, instead of giving medicine to R2, they moved to next person who is R1 and inadvertently gave the wrong medication cup to R1. Didn’t know wrong medication was given to R1 until R1 brought it up. On 01/02/2025, LPA Jain reviewed the Medication Administration Record (MAR) for R1 and R2. Records indicated that on 12/23/2024, medications were administered to both R1 and R2 in the morning. Based on interview with ED and the incident report submitted to the licensing department, RSD missed to give medication to R2. LPA Jain reviewed the note sent to R2 doctor indicating that R2 missed the morning medication. 2) For incident #2, happened on 12/22/2024, resident (R3) was found with two large bruises on the back of his right thigh and large bruise on his right hand. The origin of the bruises was unknown. LPA Jain interviewed ED. ED stated R3 is in memory care and is a fall risk. R3 walks by themselves in the hallway. Doesn’t use a walker. R3 uses a walker only when staff is nearby. R3 gets up from their bed and walks out of the room. Memory care has no bed alarms, no sensors, and no mat alerts. Care staff monitors the residents constantly. Continued on LIC-809C If resident is constantly falling, facility request family to provide a private companion for the resident. If falls can’t be controlled, then facility asks the family to move the resident to another facility. R3 is currently at the hospital due to weakness. If R3 is diagnosed of puree diet, then R3 had to go to skilled nursing home and then gets revaluated before being accepted back at the facility. LPA Jain obtained and reviewed R3’s doctor’s note received by the facility after 12/22/2024 fall, Physician’s report, Resident functional needs and service plan, preplacement appraisal information. 3) For incident #3, happened on 11/27/2024, resident (R4) had multiple fall incidents, the incident reports for these incidents were sent by the facility and received by the licensing department on 12/13/2024. ED stated the fax was sent on 11/27/2024 to the licensing department and showed the fax confirmation page for the IR sent on 11/27/2024. ED stated that they didn't receive a confirmation page from their staff and hence ED asked their staff to refax the IR on 12/13/2024. LPA Jain collected the fax confirmation page for 11/27/2024 incident that was originally sent on 11/27/2024. A deficiency was cited based on LPA observations, record reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, and Plans of Correction were reviewed and developed with the Executive Director. A copy of this report and appeal rights were discussed and left with the Executive Director, Flavio Silva, whose signature on this form confirms receipt of these documents.