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13 | Licensing Program Analysts (LPAs), Dina Alviso, and Karen Lopez, conducted a complaint inspection, on 7/23/2021 at approximately 1:42pm, and met with Shawn Mooney, Administrator, and Annet Nakiyuka, Administrator Assistant.
The LPA reviewed information provided by the reporting party(s). The LPA reviewed resident records (R1), including care plans, re-assessment(s), incidents, medical records, and in home health documents. The LPA reviewed records, and conducted interviews with staff, and other related party(s). The investigation revealed that R1 had a medication that had been dicontinued on 1/25/21 per MD Orders, and staff continued to give the medication up to 1/29/21, an am dose. This medication error was identified by review of the medication facility records, it's the medication MAR. The medication error was brought to the staff's attention, and the medication was pulled from the active prescription medications for the resident on 1/29/21.
Continued on LIC9099C... |
| Substantiated | Estimated Days of Completion: |
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NARRATIVE |
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32 | Resident medical care supplies that were left for the resident's care by home health staff , in the resident's room, were found to be missing when in home health came in to provide resident services. Per staff interviews, facility staff were not able to tell the LPA what had happened to the care supplies that had been in the resident's room. Staff had told the LPA they did not know where the supplies had gone. Health Services Director had stated to the LPA that the facility would replace items if they go missing. LPA discussed the personal belongings of residents and facility procedures. The Administrator stated that they do have residents that may grab items here and there and items are returned as best as staff can back to their resident owners. Administrator stated that clothes even from the laundry items are always being worked on getting items back to resident owners, and the items not marked with identification are the hardest to get done. There are new facility procedures going in place to help address this issue.
Per the investigation, resident had a medication that was not given as ordered by the Physician, and resident's medical/care supplies had gone missing from residents belongings.
Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegations of, staff failed to administer resident's medication as prescribed, and staff failed to safeguard resident's personal belongings are substantiated.
Due to the substantiation of the allegations, citations will be cited today-see LIC9099D.
The preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.
Appeal Rights Given. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
07/24/2021
Section Cited
CCR
87465(c)(2) | 1
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7 | Incidental Medical and Dental Care (c) (2)- Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by LPA's review of records and interviews. | 1
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7 | Administrator Shawn Mooney to ensure that the facility staff that handle medication assistance to residents in care are in-serviced on Medication Policies of the facility in regards to medication orders and discontinued medication orders. Submit copies of proof of training by 7/30/21. |
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14 | The LPA reviewed records, and conducted interviews with staff, and other related party(s). The investigation revealed that R1 had a medication that had been dicontinued on 1/25/21 per MD Orders, and staff continued to give the medication up to 1/29/21, an am dose. This medication error was identified by review of the medication facility records, the medication MAR.This is a potential health and safety risk to residents in care. | 8
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14 | Include Trainer, Topics covered, attendees, Date/Time spent.
Submit plan of correction by 7/24/21. |
Type B
08/03/2021
Section Cited
CCR
87468.1(a)(12) | 1
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7 | Personal Rights of Residents In All Facilities-(a)(12)Residents in all residential care facilities for the elderly shall have all of the following personal rights: 12)To wear their own clothes; to keep and use their own personal possessions, including their toilet articles. This requirement was not met as evidenced by LPA's review of records and interviews with staff, and outside parties. | 1
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7 | Administrator Shawn Mooney to submit new facility procedures that he stated to the LPA are going in place to help with ensuring resident belongings stay and are returned to residents rooms as required. The new procedures will be in-serviced to staff and will also be relayed to family members/residents regarding persoal items and/or missing personal items. |
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14 | Staff had told the LPA they did not know where the supplies had gone. Health Services Director had stated to the LPA that the facility would replace items if they go missing. LPA discussed the personal belongings of residents and facility procedures. The Administrator stated that they do have residents that may grab items here and there and items are returned as best as staff can back to their resident owners. Administrator stated that clothes even from the laundry items are always being worked on getting items back to resident owners, and the items not marked with identification are the hardest to get done. | 8
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14 | Administartor will submit the plan of personal belongings that are facility procedure in regards to this citation. Submit by 8/3/21. |
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13 | Licensing Program Analysts (LPAs), Dina Alviso, and Karen Lopez, conducted a complaint inspection, on 7/23/2021 at approximately 1:42pm, and met with Shawn Mooney, Administrator, and Annet Nakiyuka, Administrator Assistant.
The LPA reviewed information provided by the reporting party(s). The LPA reviewed resident records (R1), including care plans, re-assessment(s), incidents, medical records, and in home health documents. The LPA reviewed records, and conducted interviews with staff, and other related party(s). The investigation revealed that R1 had some falls, and in one fall the resident sustained a fracture; The resident also had some skin tears needing first aid by facility staff.
Continued LIC9099C... |
| Unsubstantiated | Estimated Days of Completion: |
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