Follow-up on corrections·April 28, 2022

Licensing Program Analyst (LPA) conducted a Case Management - Deficiency visit to the above facility. LPA Ascencio met with Administrator Arlene Martinez at 9:15 AM. On 4/28/2022, starting at approximately 9:35 a.m., LPA Ascencio reviewed six (6) resident files and observed that the Needs and Service Plans for Resident #1 (R1) and R2 were not updated within the last year. Later that day, at approximately 10:00 a.m., a Medication Audit was conducted. During the Medication Audit, it was revealed that R3’s Metroprolol 50mg has not been given as prescribed for the months of February, March and April 2022, Lisinopril 20mg for the month of April 2022, and Melatonin 5mg for the month of April 2022. LPA reviewed the physician’s order for R3, dated 02/27/2022, and observed that Metroprolol 50mg is to be given one (1) tab by mouth two (2) times daily, Lisinopril 20mg is to be given 1 tab by mouth 2 times daily, and Melatonin 5mg is to be given 1 tablet by mouth once daily at bedtime. LPA reviewed the Medication Administration Record (MAR) for R3 and observed that Metroprolol 50mg was only given 1 tab daily for the months of February, March and April 2022, Lisinopril 20mg was given 1 tab daily for the month of April 2022, and Melatonin 5mg was not given at all for the month of April 2022. Admin Martinez stated for the Metroprolol and Lisinopril, the prescribing doctor verbally told Admin to stop giving the medication as prescribed and to give the Metroprolol 50 mg 1 time daily and the Lisinopril 20mg 2 times daily. LPA asked for a written prescription describing the doctor’s orders. Admin stated they do not have the order. LPA questioned the Melatonin 5mg not being administered. Admin stated R3’s family member does not want that medication to be given due to the effect it has on R3. LPA requested for the written prescription from the doctor that states the discontinuation of the Melatonin 5mg. Admin stated they do not have the order. 2 citations were issued during today’s visit. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Copy of the report and appeal rights provided to Admin via email.