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25 | On 6/12/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit, met with Jessica Sanders and explained the reason for the visit.
On 6/6/24, the department received a SOC 341 submitted by the Director, Jessica Sanders. The report stated that on 6/4/24, medication tech S1 forced R1 to take medications at approximately 8 PM, after R1 had spit out R1's medications at the medication tech. S1 was assisted by caregivers S2 and S3 who restrained R1 while S1 put medications in R1's mouth and S1 covered R1's mouth so that R1 could not spit the medications out again. It is not known if resident spit out all medication in their entirety before additional medications were forced.
S4 reported the incident to the Memory Care Director on 6/5/24. S5 reported the incident to the Director on 6/6/24.
During this visit LPA interviewed the Director. Director stated S1's employment has been terminated. S2 and S3 are currently suspended pending further action.
Staff training has been reviewed for staff present that shift regarded mandated reporting, resident right to refuse meds and no restraint policy with S1-S5.. Additional staff training to be done for all staff as part of the plan of correction (POC)
LPA received copies of S1, S2 and S3 employee records, R1's physician's report and medication administrative record, staff schedules for 6/4/24, as well as staff statements, by S1-S5, collected in the course of the facility's investigation. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
06/13/2024
Section Cited
CCR
87465(a)(5)(D)
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7 | Incidental Medical and Dental Care (a)(5)(D) Assistance with self-administration does not include forcing a resident to take medication,... without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication. | 1
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7 | Director has discussed mandated reporting, resident right to refuse meds and no restraint policy with S1-S5.
Licensee will submit the training date for all staff regarding mandated reporting, resident right to refuse meds and no restraint policy. |
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14 | This requirement was not met on 6/4/24 when R1 was forced to take medications by two caregivers and a med tech.
This posed an immedicate risk to the resident. | 8
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14 | The training date will be submitted by 6/13/24.
Following completion for the training, documentation of training and participants will be submitted to CCL. |
Type A
06/13/2024
Section Cited
CCR87211(c)
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7 | Reporting requirements- (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four | 1
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7 | Director has discussed mandated reporting, resident right to refuse meds and no restraint policy with S1-S5.
Licensee will submit the training date for all staff regarding mandated reporting, resident right to refuse meds and no restraint policy. |
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14 | (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met by S1 or S2 who witnessed the incident of 6/4/24 and failed to report to police within 24 hours. This posed an immediate risk ro residents. | 8
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14 | The training date will be submitted by 6/13/24.
Following completion for the training, documentation of training and participants will be submitted to CCL. |