342700064-5-6-2024-27-AS-SRIN-D5QMJN-20240529093926

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700064
Report Date: 05/06/2024
Date Signed: 05/06/2024 01:01:30 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2024 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240405131806

FACILITY NAME:	GRAMERCY COURT		FACILITY NUMBER:	342700064
ADMINISTRATOR:	CYSEWSKI, TRISA		FACILITY TYPE:	740
ADDRESS:	2200 GRAMERCY DRIVE		TELEPHONE:	(916) 482-2200
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	85	CENSUS: 81	DATE:	05/06/2024
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Veronica Morales		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff gave wrong medications to resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a complaint investigation visit and deliver complaint investigation findings.

LPA Valerio met with Skilled Nursing Administrator Nima Pourfathi and Memory Care and Assisted Living Administrator Veronica Morles, and explained the purpose of the visit.

During today's visit, LPA Valerio interviewed staff, reviewed facility records, and observed the facility. The facility was observed to be clean, free from debris, and free from obstructions of emergency exits. No immediate health or safety concerns were observed.

The Department has determined the following as it relates to the following allegation: Staff gave wrong medications to resident in care
Continues on LIC 9099 - C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240405131806

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRAMERCY COURT	FACILITY NUMBER: 342700064
	VISIT DATE: 05/06/2024

NARRATIVE

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Continues from LIC 9099

Based on records review and information from the Reporting Party (RP), the facility administered medications for Resident 1 (R1) to Resident 2 (R2). Facility Staff, Staff 1 (S1), realized the error after checking the computer system. According to S1, S1 notified the Wellness Nurse Supervisor immediately after the error.

It was confirmed by interviews with Designated Administrator, Wellness Nurse, and Staff 1 that R2 was provided the wrong medications.

Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached LIC 9099 - D page.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240405131806

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRAMERCY COURT	FACILITY NUMBER: 342700064
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/06/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/07/2024 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...:(5) Facility staff, ...designated by the licensee may assist persons with self-administration as needed....This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee stated they provided an in-service to the staff on the topic: The Six Rights of Medication Administrator. Licensee to submit a copy to LPA by POC due date.
	8 9 10 11 12 13 14	Based on records review and interviews, the licensee admitted that R2 was given R1's medication, which poses an immediate health, safety, and personal rights risk to residents 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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2024 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240405131806

FACILITY NAME:	GRAMERCY COURT		FACILITY NUMBER:	342700064
ADMINISTRATOR:	CYSEWSKI, TRISA		FACILITY TYPE:	740
ADDRESS:	2200 GRAMERCY DRIVE		TELEPHONE:	(916) 482-2200
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	85	CENSUS: 66	DATE:	05/06/2024
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Veronica Morales		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff did not seek timely medical care for resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a complaint investigation visit and deliver complaint investigation findings. LPA met with Administrator Veronica Morales, and explained the purpose of the visit.

The Department has determined the following as it relates to the following allegation: Staff did not seek timely medical care for resident in care

Based on information from the Reporting Party (RP), Resident 2 (R2) was given Resident 1 (R1) medications; however, RP stated that the facility did not contact the family or call the ambulance until two hours after the incident. It was reported that R2's family contacted the facility during the time frame but did not reach anyone at the facility to discuss the issue.

Continues on LIC 9099- C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20240405131806

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRAMERCY COURT	FACILITY NUMBER: 342700064
	VISIT DATE: 05/06/2024

NARRATIVE

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Continued from LIC 9099
The RP learned of the medication error after receiving an Unusual Incident Report (UIR) on 02/13/2024 from the facility. The UIR stated that the medication error occurred on 12/18/2023. According to the UIR, the staff contacted the "LN" (Lead Nurse), which then contacted emergency medical services (EMS). R2 was transported via Alpha One to the Emergency Room and came back the next day with no orders or discharge information. According to the RP, the incident occurred at or around 9:34 AM and the family was not spoken to until 11:42 AM.

According to a review of the facility records, a note was written on 12/18/2023 at 09:36 AM. Note stated the following: "Resident was given the wrong medications by error. Residents' son and PCP notified. Alpha one called and resident sent to Kaiser ER for evaluation".

According to an interview with Administrator Veronica, the facility usually writes the time of when people are contacted; however, during this incident, the times were not written.

According to interviews with facility staff, all staff deny delaying a call to EMS. Based on interviews with staff, all staff state that EMS was contacted immediately after the incident. Staff also stated that they spoke to staff during the incident and after the incident had occurred

According to a review of the facility records, a note was written on 12/19/2023 14:27 (2:27PM). Note stated, "Resident came back from the hospital around 1:52 P.M. with the daughter. Per RCC, there are no changes of medication and no discharge paper as well. Wellness Nurse and Administrator and Other RCC was informed, also faxed PCP."

Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited regarding the above-mentioned allegation.
An exit interview was held and a copy of report was left at the facility.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

LIC9099 (FAS) - (06/04)

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