On 10/04/2023, Licensing Program Analysts (LPAs) Sarena Keosavang and Bethany Mirlohi arrived at the facility unannounced to review clients’ medications. LPAs reviewed C4’s medication records and doctor’s orders to ensure there were no discrepancies. LPAs conducted medication count and discovered discrepancies. Medication Lisinopril (10mg, take 1 tablet by mouth daily) start date was 7/25/2023 and the quantity was 90 pills. LPAs counted the remaining pills left in container was 23 pills. Total numbers of days from medication start date to 10/04/2023 is 72 days. The correct total number of pills that should be in the medication container is 18. There were additional discrepancies that were observed for medication Montelukast (10mg, take 1 tablet by mouth every evening). The start date for Montelukast was 7/22/2023 and the quantity is 90 pills. LPAs counted 23 pills in the medication container. The total number of days from start date to 10/04/2023 is 75 days. Correct total number of pills that should be in the medication container is 15.

On 10/25/2023, Alta Regional Center conducted an unannounced visit to the facility to review medications due to ongoing medication system concerns. The following deficiencies were identified. Client’s bubble pack of Omeprazole 20mg, 1 cap daily started 10/15/2023. There were 12 caps not present. Based upon the start date 11 caps should have been administered; there is one cap unaccounted for. The start date was not identified on the centrally stored medication log. An SIR was requested for the medication that was unannounced for. The start dates for Lisinopril, escitalopram,montelukast were not identified on the centrally stored log. The facility did not report medication error to Community Care Licensing. LPA requested for incident report to be submitted for review.

The facility did not submit incident reports for medication error to Community Care Licensing for review.

Allegation: Facility is inaccurately documenting medication administration. – Substantiated.

On 9/14/2023, Alta Regional Center conducted an announced visit to review medications. At the visit on 9/18/2023, Alta Regional Center observed that the MARs had not been signed since the morning of 9/14/2023 for all clients’ medications. According to C1’s MAR, medication Alendronate Sodium is to be given 1-tab every7 days. Per administrator, the medication is administered on Mondays. The MAR was not signed for Monday, 9/18/2023. The noted start date on the box was 9/17/2023. The start day was not identified on the Centrally Stored Medication Records and Destruction Record. Administrator stated the medication was given the morning of 9/18/2023, not 9/17/2023 as identified.

On 10/04/2023, Licensing Program Analysts (LPAs) Sarena Keosavang and Bethany Mirlohi arrived at the facility unannounced to review clients’ medications. LPAs reviewed C1’s medication records and doctor’s orders to ensure there were no discrepancies. According to C1’s physician’s communication with the facility, C1’s procedure has been postponed. Preparations were defined which include holding R1's Alendronate and Vitamin Supplements about a week prior to 10/06/2023. On 10/03/2023, the undersigned received a call from Kaiser that the 10/06/2023 procedure was being postponed indefinitely. A check with the surgeon's staff confirmed this change, therefore, to resume the administration of the withheld meds until further notice. The facility asked the physician if C1’s medications that were being held (Alendronate and vitamin supplements) are to be resumed. On 10/3/2023 at 1:05 PM, C1’s physician stated C1 can resume medications and supplement at this time. LPAs conducted medication count and observed Alendronate was given on 9/30/2023 and 10/01/2023. Calcium was given on 9/30/2023. According to records, C1’s scheduled procedure is on 10/6/2023. According to Physician’s order, the two medications (Calcium and Alendronate) should have been held a week prior to procedure date. Medications should have been held from 9/29/2023 through 10/6/2023. It was discovered that withheld medications ordered by C1’s physician were given to C1.

LPAs requested for administrator to submit incident reports to Community Care Licensing and Alta Regional Center for review. The Department did not receive incident reports from the facility.

On 11/28/2023, LPA Cheyenne Ratajczak, LPA Talwinder Bains, and Licensing Program Manager (LPM) Laura Munoz conducted a case management inspection. The purpose of the case management inspection is to follow up on several Title 17 reviews conducted at this facility by Alta Regional Center (ACRC) between 7/24/2023 and 11/7/2023. Facility Action Reports (FARs) were generated by ACRC from Title 17 reviews. CCL received a copy of the FARs and it was noted in the FARs the facility was cited for violations that are in both Title 17 and Tittle 22. The case management inspection is to address the issues found in the FARs that apply to Title 22. Deficiencies were identified and citations were given during the visit.

On 8/3/2023, it was discovered that staff training requirements hours were not being met. On 11/28/2023, LPA Cheyenne Ratajczak, LPA Talwinder Bains, and Licensing Program Manager (LPM) Laura Munoz conducted a case management inspection. The purpose of the case management inspection is to follow up on several Title 17 reviews conducted at this facility by Alta Regional Center (ACRC) between 7/24/2023 and 11/7/2023. Facility Action Reports (FARs) were generated by ACRC from Title 17 reviews. CCL received a copy of the FARs and it was noted in the FARs the facility was cited for violations that are in both Title 17 and Tittle 22. The case management inspection is to address the issues found in the FARs that apply to Title 22. Deficiencies were identified and citations were given during the case management visit on 11/28/2023.

Based on interviews and records review, the Department finds the above allegations to be SUBSTANTIATED. A finding that the allegation is substantiated means that the allegation is valid because of the preponderance of the evidence standard has been met.

An additional deficiency will be provided during today’s visit under Title 22. See LIC 9099-D

Exit Interview conducted and copies of report provided.

According to interviews received, the facility gave C1 double doses for five (5) days of prescribed medication, Clopidogrel. Facility staff were not aware C1 was given double doses of a prescribed medication and was discovered during a Title 17 review visit.

The facility submitted an incident report to CCL for review. According to incident report, C1 was admitted to Mercy Medical Center for two reasons on 9/18/2023. An ongoing audit of C1’s medications indicate the possibility of an overdose of blood thinner (Plavix). Two, the swelling of C1’s right arm (a condition that had been checked in the same facility) about 2 weeks prior. C1 was brought to the Emergency Department from the facility at a bout 11:20 AM. The blood test to check the possible effect of the double dosing of the medication did not show any red flag. The physician though was baffled by the tenacity of the medical condition causing the swelling of C1’s limbs. After an antibiotic treatment (7 days) follow by a Prednisone treatment (5 days), no perceptible improvement seems to have occurred. Further tests were conducted including Magnetic Resonance Imaging (MRI). In the end they decided to admit C1 to the hospital for furth observation and to try stronger intravenous fed antibiotics. At about 10 PM, the medical staff decided to admit C1, and the facility’s personnel were asked to leave the facility. Alta Regional Center (ACRC) has been looking for an alternate home for C1 since C1 care needs have reached a level which is not within the capability of a level 3 home. The administrator was informed by ACRC that a higher-level vendor has shown interest in admitting C1.

The Department subpoena medical records for C1. According to medical records, C1 was admitted to the hospital on 9/25/2023 and was discharged from the hospital on 10/2/2023. The medical record states C1 was brought to Mercy San Juan Medical Center (MSJMC) ER with right face droop and speech difficulty and to be evaluated because of possible stroke. C1 was discharged due to right upper cellulitis with sepsis associated with metabolic encephalopathy improved. C1 was initially treated with empiric IV antibiotics Vancomycin and Zosyn, C1 was evaluated by orthopedic surgeon, MRI of the upper extremity was done showing no substantial tenosynovitis, superficial soft tissue swelling above the wrist and proximal hand no abscess. C1 was discharged on Doxycycline and Cephalexin. As per ED report, C1 was noticed to have facial droop and dysarthria. Discharge summary indicates C1 has Candiduria. Daily wound care per recommendations of wound care staff. Wound Care tea, assessed at bedside. Recommend frequent repositioning, C1 has off-loading heat boots on. Wound to left lateral heel is dry and stable, okay to leave. Bilateral hips have scar tissue from previously healed pressure injuries, foam dressing applied for protection.

Based on records review of medical records obtained from MSJMC, there was no indication of any medication errors, abnormalities of high doses of medication or cause of concern by the doctor. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Exit Interview was conducted, and a copy of this report has been provided.