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13 | On 02/12/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a subsequent complaint visit and delivered complaint findings on the above allegations. LPA introduced self, stated the purpose of the visit and met with Tasha Duncan. Administrator Kala Gibson was called and unable to attend meeting.
During the course of the investigation, the Department conducted interviews. It was confirmed that R1 had requested to be taken to the hospital and the staff refused for the resident to go. R1’s medications and Medication Administration Record (MAR) were reviewed and observed resident’s medication were not administered to resident as prescribed on multiple occasions. Based on interviews conducted, records reviewed, and observation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 is being cited on the attached Lic 9099D. An exit interview was conducted. A copy of this report and appeal rights was provided to staff, whose signature confirms receipt of this report.
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| Substantiated | Estimated Days of Completion: |
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Under Appeal
Type A
02/13/2024
Section Cited
CCR
87468.1(a)(16) | 1
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6
7 | Personal Rights of Residents in All Facilities To receive or reject medical care or other services.
This requirement was not met as evidenced by:
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7 | Licensee shall submit a written statement of the understanding the regulation and how it will be met by POC due date 02/13/24. |
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14 | Based on interviews conducted, the resident had requested to go to the hospital and the facility staff refused to call for the resident to be taken to the hospital, which poses an immediate health and safety risks to persons in care.
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14 | In-service training for all staff will be completed for “Personal Rights.” In-service training documents with staff attendance shall be submitted to the Fresno CCL office by POC due date 02/26/24.
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Type A
02/13/2024
Section Cited
CCR
87465(c)(2) | 1
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7 | If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration…(2)… the medication is given according to the physician's directions.
This requirement was not met as evidenced by:
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7 | Licensee shall submit a written statement detailing steps the facility will take to ensure the requirements of Health-Related Services are met. Statement shall be submitted to Fresno CCL office by POC due date 02/13/24. |
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14 | Based on interviews conducted, records reviewed and observation, R1’s medication and MARs were reviewed and observed that staff did not administer medication: Lidocaine 5% patch at 7AM for multiple dates in February 2024, on 2/9/24 7PM and 2/11/24 7PM. Medication Morphine 15mg was not administer on 2/9/24 8PM and 2/10/24 8PM. Morphine 15mg was administered on 2/10/24 and 2/11/24 after medications were changed on 1/29/24 to Morphine 30 mg. Medication Morphine 30 mg was not administer on 2/10/24, 2/11/24 8AM, and 2/12/24 8AM. Medication Valproic Acid 250 mg was not administered on 2/5/24 12PM and 2/11/24 8PM. Diclofenac Sodium 1% gel was not administered on 2/6/24 8AM and 2/7/24 8AM. Several medications not being administered to R1 poses an immediate health and safety risks to the person in care. | 8
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14 | All staff will be retrained on Health-Related Services regulations which includes medication pass and medication checks. Training documents and record of staff attendance will be submitted to the Fresno CCL office by 02/26/24. |
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13 | On 02/12/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to delivered complaint findings on the above allegation. LPA introduced self, stated the purpose of the visit and met with Tasha Duncan. Administrator Kala Gibson was called and unable to attend meeting.
During the course of the investigation, the department conducted interviews, reviewed records, and toured the facility. Staff initials and documented in the resident’s Medications Administration Record (MAR) when medications were administered. Based on interviews conducted and records reviewed, S1 was not working when S1 was observed to appear intoxicated. Therefore, based on interviews conducted, records reviewed, and observation, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was provided to staff, whose signature confirms receipt of this report.
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| Unsubstantiated | Estimated Days of Completion: |
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