347001498-7-20-2023-59-AS-MSEY-CTXPHV-20230721112031

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001498
Report Date: 07/20/2023
Date Signed: 07/20/2023 01:27:22 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
06/26/2023 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230626105103

FACILITY NAME:	CITRUS HEIGHTS TERRACE		FACILITY NUMBER:	347001498
ADMINISTRATOR:	EDITHA MCCULLOUGH		FACILITY TYPE:	740
ADDRESS:	7952 OLD AUBURN ROAD		TELEPHONE:	(916) 727-4400
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	45	CENSUS: 45	DATE:	07/20/2023
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Editha Mc Cullough, Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff are mishandling resident's medication.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the complaint investigation and deliver findings for the above allegation. LPA met with Editha McCullough, Interim Administrator, and explained purpose of inspection.

During the investigation, LPA interviewed (2) Med-Tech staff and the Administrator. LPA interviewed (1) resident and attempted to interview (2) residents but was unable to obtain any pertinent information. LPA also reviewed medications being administered to (3) residents, including the associated orders and documentation, and toured the interior of the community. The results of the investigation are as follows:

Both Med-Techs stated they occasionally do find a pill or medication on the floor as there are a couple of residents who pretend to take their medication and "pocket it", but most residents “know their routine” and are generally good at taking their medication. One Med-Tech indicated that she and other staff do document when a resident refuses medications and also inform the physician.
cont on 9099C(1)..

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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 59-AS-20230626105103

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CITRUS HEIGHTS TERRACE	FACILITY NUMBER: 347001498
	VISIT DATE: 07/20/2023

NARRATIVE

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9099C-1... One staff stated medications are sometimes not ordered timely, explaining each Med-Tech is in charge of ordering medications. Staff explained that the facility previously tried a system of ordering 7 days out, but it didn't work, and sometimes a resident will not start an antibiotic medication until the next day and they receive their first dose at the hospital. (1) resident who was interviewed stated he has not had any issues with receiving medications and they are the same every day.

Medication being left out. LPA toured the facility on 6/28/23, 7/6/23, 7/13/23 and 7/20/23 and did not observe any unsecured medications to be on the floor or in the resident hallways. Staff interviewed stated medications are delivered using the med cart and usually "we administer them in the dining room- there are more eyes on the meds with dining staff there". LPA observed both dining rooms on 7/20/23 and did not observe any medications on the floor during/after S1 administered noon medications to a few residents.

LPA and S1 conducted a medication audit for (3) residents on 6/28/23 in the facility medication room. Medication orders were compared to medications being administered and documentation on the Centrally Stored Medication List (LIC622) and Medication Administration Record (MAR) was reviewed. The following discrepancies were noted for (2) residents, as follows:

For resident (R1)- There were no errors in (11) of (15) medications. Medication counts on hand did not match with the start date entered on the LIC622 for Cranberry supplement, Multi-Vitamin Centrum, Divalprox and Olanzapine, showing a discrepancy of (2) to (12) days. There was no start date listed on the LIC622 for Senna 17.2 mg and PRN Olanzapine, 5mg- expired 4/12/23. New medication of Olanzapine was ordered on 7/8/23 and will be received by 7/28/23. S1 stated resident has not taken this recently as it has not been needed. There were (2) lose pills observed in resident's red centrally stored box that appeared to have fallen out of the bubble pack. Medication was discarded per protocols.

For resident (R2)- there were no medication errors noted on (3) of (3) medications and there were no lose pills in the red centrally stored box.

For resident (R3)- There were no errors in (5) of (7) medications reviewed. The medication Fluoxetine 20 mg was missing (1) tablet based on the start date and medication count. The medication Risperidone 0.5 mg, ordered to be given as (1) tablet in the morning and (2) at bedtime, a start date of 6/10/23 was noted on the LIC622. There was no start date entered on the 30-day bubble pack. (13) tablets were administered on 6/28/23 (4:00 pm), or (4) days plus a morning dose, if administered as ordered. The medication count didn't match the start date entered on the LIC622. There were no lose pills in resident's red centrally stored box.

cont on 9099C-2.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230626105103

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CITRUS HEIGHTS TERRACE	FACILITY NUMBER: 347001498
	VISIT DATE: 07/20/2023

NARRATIVE

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9099C-2... Based on information obtained and reviewed, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page.

Exit interview. Copy of report and appeal rights provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 59-AS-20230626105103

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CITRUS HEIGHTS TERRACE	FACILITY NUMBER: 347001498
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/31/2023 Section Cited CCR 87465(a)(4)	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. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to conduct staff training on medication management to include topics: Correct documentation by staff on the MAR and LIC622; how to log a new or refilled medication; importance of entering start date on the LIC622; process of calling timely for a refill Any other medication related topics
	8 9 10 11 12 13 14	Based on medication count and record review on 6/28/23, the Licensee did not ensure that medications were administered as ordered for residents (R1 and R3), which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Documentation to be provided to CCLD by 7/21/23 by email/fax of all Med-Tech staff. LPA observed documentation of completed training for "Medical Error Prevention" for (S2) on 7/17/23 and a new staff is in the process of completing.
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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: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC9099 (FAS) - (06/04)

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