496803698-5-19-2023-21-AS-HDBI-CS6UUT-20230525155405

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 05/19/2023
Date Signed: 05/19/2023 10:01:07 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2023 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230518111323

FACILITY NAME:	VINEYARD AT FOUNTAINGROVE, THE		FACILITY NUMBER:	496803698
ADMINISTRATOR:	ERIC PERRY		FACILITY TYPE:	740
ADDRESS:	200 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 544-4909
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	64	CENSUS: 44	DATE:	05/19/2023
		UNANNOUNCED	TIME BEGAN:	08:24 AM
MET WITH:	Eric Perry (Executive Director/Administrator)		TIME COMPLETED:	10:16 AM

ALLEGATION(S):

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Staff mismanaged resident's medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra arrived unannounced to initiate a complaint investigation regarding the allegations listed above and met with Executive Director, Eric Perry.

There is an allegation of staff mismanaged resident's medication. Per Reporting Party, Resident (R1) was given Coumadin for the first week of their admission back in March 2023, then staff did not give the resident Coumadin (Warfarin) on March 21,22,24 and 27, 2023 due to medication was not included in the facility medication administration records (MAR). In April 2023, R1's anti-coagulation medication was increased to 4 1/2mg (miligrams) on Mondays (M), Wednesday (W), Thursday (Th) and Friday (F). Also, 3mg on Tuesdays (T). Per supporting documentation obtained Kaiser faxed over the instructions/ordering on 4/24/23 and then called the facility to make sure the facility received the new increase order but there was no confirmation received from the facility. On 5/8/23, the clinic spoke to the facility nurse and gave them verbal instructions for the increase in Coumadin. However, staff did not increased R1's medication.
Continues on LIC9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 21-AS-20230518111323

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VINEYARD AT FOUNTAINGROVE, THE	FACILITY NUMBER: 496803698
	VISIT DATE: 05/19/2023

NARRATIVE

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Continued from LIC9099...

On 5/17/23 the facility submitted a self-incident report to CCL regarding R1's medication error. Per incident report, on 5/14/23 R1 went to Kaiser for a doctor's appointment and lab tests related to the medication that needed to be done revealed some discrepancies between the expected results and the increase of medication. The facility was contacted by Kaiser inquiring about administration of prior order for Warfarin sent on 5/8/23. Upon review, it was discovery that two medication errors have been made when entering that order into the electronic MAR. The order was entered to end on 5/14/23, but no new orders were sent until 5/16/23 so R1 did not receive medication on 5/15/23. Also, it was revealed that the medication was entered incorrectly as 4.5 mg (1 1/2 tabs T-S) and 6 mg (M), but instead it was incorrectly entered as 3 mg (1 tab T-S) and 6 mg (M). The facility corrected the entry into the electronic MAR with no end date as ordered, administered starting on 5/16/23 as ordered by R1's Physician and notified responsible parties including CCL.

During today's visit, LPA conducted confidential interviews and reviewed records provided by the facility with pertinent documentation indicating that R1 was assisted with medication dosage as prescribed by their Physician in March 2023. However, it was confirmed by Executive Director that there was a medication error above described regarding R1's medication. After investigation, it was determined that facility nurse entered the order incorrectly into the electronic MAR resulting in R1 not receiving their medication on 5/15/23. LPA learned that the facility have implemented an alert charting and interim service regarding new order that it was reviewed by Regional Nurse Consultant and agreed to prevent this incidents from happening again, the facility nurse will not set an end date to orders into the MAR unless the order has a specific end date due to the confusion that was directly related and resulted in R1's missed medication. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D and immediate civil penalties in the amount of $250 due to repeated citation within 12 month period. Appeal Rights Given.

Exit interview was conducted with Administrator and a copy of this report was given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20230518111323

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VINEYARD AT FOUNTAINGROVE, THE	FACILITY NUMBER: 496803698
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/20/2023 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465(a)(5)-Incidental Medical and Dental Care: The Administrator shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Executive Director/Administrator agreed to submit a written plan regarding new interim system implemented to handle new orders to be included into their facility program plan by POC due date. *Immediate civil penalties in the amount of $250 are issued due to repeated citation within 12 months.
	8 9 10 11 12 13 14	Based on a self-report submitted by facility, a staff did not administer Warfarin medication to R1 as prescribed by their Physician which is an immediate Health and Safety risk to the resident(s) in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC9099 (FAS) - (06/04)

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