Incident investigation·June 5, 2023

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Pacifica Senior Living Vacaville for the purpose of following-up on incident reports that were forwarded to the Regional Office (RO). LPA was met by Administrator, Jeffery Gollihar, and was granted access into the facility. CCL received an incident report on May 10, 2023 indicating a medication error. The error occurred on May 09, 2023 while Med Tech was dispensing medication. R1 was given the wrong prescribed medication during medication passing and was up all night. Administrator acknowledged the error and was educated on the importance of the facility dispensing the correct medication to residents in care. Responsible party and prescribing doctor were notified of medication error. LPA obtained a copy of the Medication Assessment Record (MAR) for the month of May 2023 (See LIC 809D). CCL received an incident report indicating a fall that occurred on Mary 9, 2023 and an update occurring on May 16, 2023. The incident occurred while resident was going to use the restroom, but fell. Resident was subsequently hospitalized and then discharged to a Skilled Nursing Facility (SNF) for rehabilitation due to the fall. Appropriate parties were notified in a timely manner. Resident has discharged from the facility to the SNF for a long term period and is no longer residing at the facility. Deficiencies were not cited as proper Reporting Requirements and appropriate parties were notified in a timely manner. CCL received an incident report and an SOC 341 on May 22, 2023. The incident occurred on May 17, 2023 when the Responsible Party/son came to pick up the resident, but the resident refused to get in the car. Responsible Party/son yanked him into the car, screaming and yelling. Facility's contingency plan was to review the Care Plan and update the Medication with the Primary Care Physician. All appropriate parties were notified. Currently, the resident is at a Skilled Nursing Facility (SNF) for rehabilitation purposes and for wound treatment. Resident has discharged from the facility to the SNF for a long term period and is no longer residing at the facility. Deficiencies were not cited as proper Reporting Requirements and other agency contacts were notified. A Deficiency is cited for the Medication Error occurring on May 9, 2023 from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights were given.