Incident investigation·December 4, 2024

On 12/4/24 LPA Santino Fortes conducted an unannounced Case-Management and met with Administrator (ADM) Karen Nikolai. The purpose of the visit was to follow up regarding an Incident Report submitted by facility to the Department on 11/28/24. The incident report stated that Resident R1 entered the kitchen area in the memory care unit and grabbed another resident's medications from staff S1's medicine distribution tray and consumed them. The incident report states that R1 has been on heightened observation for 72 hours and is currently doing well. During visit LPA interviewed Staff S1 who was the Medication Technician who was administering medication when R1 accessed and consumed the medication. During Interview, S1 stated that the medication tray was on a kitchen counter and within arms reach of S1. S1 stated the medications were not left unattended. The kitchen swing door was not locked which allowed R1 access to the kitchen area and the medications. During visit LPA discussed with ADM about ensuring staff lock the kitchen swing door in the memory care area so that residents do not have access to medications in the kitchen area. S1 will review proper medication handling techniques with ADM and actively lock medication tray immediately after each distribution of medications to residents. A Technical violation was issued. See LIC9102 Advisory note for more information. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with ADM Karen Nikolai and a copy of this report was provided