347003712-4-14-2021-25-AS-MHOD-C23SFT-20210414135051

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347003712
Report Date: 04/14/2021
Date Signed: 04/14/2021 01:51:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	BROOKDALE CITRUS HEIGHTS		FACILITY NUMBER:	347003712
ADMINISTRATOR:	SCARBERRY, JENNIFER		FACILITY TYPE:	740
ADDRESS:	7375 STOCK RANCH RD		TELEPHONE:	(916) 729-2722
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95621
CAPACITY:	56	CENSUS: 19	DATE:	04/14/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Sharon Monck, Acting Administrator		TIME COMPLETED:	01:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Michael Hood and Bethany Mirlohi met with Acting Administrator, Sharon Monck, to conduct a case management visit. The purpose of the visit is to follow-up on three incident reports that were received by the Department. According to first incident report, on 1/6/2021, hospice nurse was scheduled to apply a fentanyl patch for resident R1 but found that the facility did not have the patches necessary to administer the medication. LPAs interviewed medication technician (Med-Tech) and nurse, as well as reviewed R1's MAR and controlled medication binder, regarding incident on 1/6/2021. LPAs observed that fentanyl patch was administered on 1/3/2021. Med-Tech stated that fentanyl patch needs to be re-administered every 72 hours. Med-Tech stated that facility staff did not communicate with hospice regarding the reorder for fentanyl patches for R1. Due to lack of communication, R1 did not receive medication on schedule. According to second incident report, on 3/11/2021, a PM shift medication aide reported that they forgot to administer medication, Norco 10-325 mg, for R2 on 3/10/2021. Medication count on Narcotic sheet did not match medication amount on hand. An investigation was conducted by the facility, which determined that R2 missed medication on 3/8/2021 and 3/10/2021. In addition, during interviews with staff, LPAs found R2 to have a missing tablet for the same medication. According to third incident report, on 3/23/2021, hospice nurse noticed during administration of fentanyl patch for R2 that patch was not changed on 3/20/2021 by a hospice nurse. Report continued on 809-C

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: BROOKDALE CITRUS HEIGHTS	FACILITY NUMBER: 347003712
	VISIT DATE: 04/14/2021

NARRATIVE

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LPAs reviewed MAR for R2 and confirmed missing administration of fentanyl patch on 3/20/2021. MAR was missing information regarding reasons for missed medication.

LPAs reviewed resident R3's medications in relation to R3's MAR. LPAs observed R3 had an order for medication Loperamide. However, ordered medication was missing in medication cart. LPAs also observed 2 medications for R3 in cart that had no active orders in R3's MAR.

Incident reports indicated that in-services were completed for staff regarding medication errors and communication with hospice. Staff were notified to inform hospice if medication supply was running low.

As a result of today's inspection, deficiencies are being cited in regards to medication errors per California Code of Regulations, Title 22, on 809-D.

Exit interview was conducted with Acting Administrator. A copy of this report and appeal rights were provided. The Acting Administrator’s signature on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: BROOKDALE CITRUS HEIGHTS	FACILITY NUMBER: 347003712
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/15/2021 Section Cited	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 (...) by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the facility did not ensure residents are receiving medications as perscribed, which poses an immediate health, safety, and personal rights risk to the residents in care.	8 9 10 11 12 13 14	Acting Administrator will submit to LPA information regarding in-service training, including time and date of in-service and training material, as well as the date in which medication audit will be conducted, by POC due date of 4/15/21.
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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: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

LIC809 (FAS) - (06/04)

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