Non-compliance follow-up·December 12, 2024

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Legal Non-Compliance Case Management inspection. The following items were indicated as deficient in the most recent audit dated 12/2/24: Pharmacy transaction binder not organized and/or complete in Memory Care (building not specified) Resident call/signal/pager system was not operating properly in that facility having issues with resetting First Aid Kits missing items Medication requiring refrigeration temperature log was missing signatures Narcotics being signed off and counted for each shift log was missing signatures The following items are some of the requirements required per the current Stipulation and Waiver and Order (dated 6/30/22) in place for the facility: All staff that provide medication administration must receive one additional hour of training every month Pacifica shall perform quarterly audits of medication inventory and if errors are found, a plan of correction for each error found shall be included with the applicable audit report Memory Care Unit and Assisted Living unit shall be staffed independently, such that the units do not share direct care staff. The Med Tech will not be a direct care staff, but may provide support when not distributing medication. Facility call system and delayed egress shall at all times be fully functional As pertains to item #2, LPA observed signature missing on narcotics log check for this morning 12/12/24. Staff (S2) advised LPA that she hadn't signed the log yet. The time was 12:38pm. Audit identified the same issue on 12/2/24. Plan of correction not received when audit was submitted as required by the current Stipulation and Waiver and Order in place for the facility. Continued on 809C... Continued form 809... As pertains to item #3, LPA observed two [2] staff present Memory Care building 1 (MC1) but no med tech present. LPA reviewed facility staff schedule for 12/12/24 and found that S2 was scheduled to rotate between Assisted Living (AL) and MC1. LPA verified schedule is current and accurate with S2. Therefore, facility was found to be deficient in requirement required as part of the current Stipulation and Waiver and Order in place for the facility ( deficiency cited, see 809D **civil penaltiy assessed** ). As pertains to item #4, LPA observed the pendant call button system to not be properly working. LPA interviewed resident in room 101 (R2). LPA pressed resident's pendant at 11:34am. Staff (S1) arrived at 11:42am to room 101 to take the resident down for lunch. LPA asked caregiver if they were here to answer the pendant call, they said no, and explained that they did not receive a page and were here to take the resident to lunch. Care giver then proceeded to wheel the resident down to the dining area. Admin was approaching down the hall as S1 was leaving. LPA advised Admin of pendant alarm not working. LPA confirmed with Admin that pendant flashed red when LPA pressed it. The pendants flash red when they are activated then turn green once reset/answered by staff. The staff are to receive a page when the pendant is pushed and the call is also logged on the pendant/call button computer. Admin and LPA went to review computer call button log and there was no call showing from room 101. Admin went to resident in dining hall and pressed resident's pendant, S1 was present as well. Once again S1 did not receive the page and the call request was not logged on the call button computer log. Issue reported in audit dated 12/2/24 was "Resident call/signal/pager system was not operating properly in that facility having issues with resetting." However, no plan of correction was submitted with audit as required by the current Stipulation and Waiver and Order in place for the facility ( deficiency cited on annual inspection 809D dated 12/12/24 ). One [1] staff (S6) out of three [3] staff identified in audit as having completed orientation training and CPR card on file were found to actually not be on file and not issued. LPA confirmed with Admin that S6 does not have completed orientation training and current CPR card ( deficiency cited on annual inspection 809D dated 12/12/24 ). Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Admin. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given .