Incident investigation·September 2, 2021

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Licensee, Nick Aquino. LPA conducted risk assessment call with Licensee prior to visit. LPA arrived at the facility and had her temperature checked and was logged into a sign-in sheet. However, the staff did not ask any of the screening questions to LPA. Licensee and LPA discussed the importance of screen visitors. LPA is following up regarding five incident reports received involving resident (R1) had trouble breathing. On 6/2/21 R1 complained about difficulty breathing and was transported to Santa Rosa Memorial Hospital. R1 and was diagnosed with Dyspnea and was prescribed new medication Prednisone 10mg for 4 days. R1 is a heavy smoker and was instructed to limit cigarette intake and responsible party agreed with Administrator to reduce the amount of money from $60 to $30 for cigarettes. On 6/7/21 R1 was having trouble breathing and was transported to Santa Rosa Memorial Hospital. Administrator agreed with responsible party that no more money was going to be provided to R1 until their smoking habit changes. On 8/1/21 R1 had trouble breathing and was transported to the hospital were received a diagnosis of Emphysema. R1 smokes an average of 3 packs of cigarette per day and responsible party provided Lozenges to help with smoking issue. R1 on 8/5/21 had a hard time breathing and received an increase of medication Prednisone 50mg tablet and azithromycin 250 mg tablets for Chronic Obstructive Pulmonary Disease. Once again on 8/11/21 R1 was transported to the Hospital due to difficulty breathing and no new or adjusted medication order was prescribed. According with Licensee, Facility has developed a plan to help R1 to quit smoking. LPA also discussed with Licensee the importance of update R1's care plan to include recent diagnosis and make sure that the facility can provide the care and supervision that meets resident needs. As of today, R1 has not experienced any incidents. Licensee mentioned to LPA Facility is working with resident's responsible party and case worker to help R1 to quit smoking. Continues on LIC809C... Continued from LIC809... Discharge documents dated 6/4/21 indicated that R1 has medical issues as asthma with acute exacerbation, COPD exacerbation, schizophrenia and tardive dyskinesia. LPA also reviewed R1’s care plan dated 5/5/20 encouraged R1 to stop smoking. At approximate 10:30am LPA/Licensee/staff conducted a spot check of R1's medication and observed multiple medication errors. Facility provided R1's Medication Assistance Records (MARs) for the month of August 2021 revealed R1's medications were not entered for the month of September 2021 by staff. Also, Centrally Stored Medication Records printed at the time of visit indicated medication records has not been updated in the system by staff for 7 out 7 prescribed medication (Gabapentin 800mg, Atorvastatin 10mg, Haloperidol 5mg, Ziprasidone 80mg, Omeprazole 10mg, Vitamin D3 and Morphine Sulfate 15mg). LPA/Licensee contacted staff (S1) and S1 assures that R1 was assisted with the administration of medications as prescribed per physician’s order. However, S1 could not provide any proof or explanation about the missing filled date and start date on R1’s bubble packs medication and in the Centrally Stored Medication Records. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Civil Penalties are also being assessed in the amount of $250 due to a 2nd repeat citation issued for the same sections in less than 12 months. *****Total Civil Penalties issued today in the amount of $250.00