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13 | Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 12/20/23 at approximately 9:30am, met with Administrator Jana O'Sullivan, and H&W Director Janice Foster. LPA reviewed resident records, R1 & R2 records, and facility records. LPA conducted interviews with staff, S1, S2, and other related parties.
The investigation revealed that R1 had a prescription medication go out of the community with another resident's, R2, medications who had moved out of the facility. R2's responsible party contacted the facility regarding the medication that was not R2's that was included with R1's upon their discharge from the facility. Responsible party stated they would return R1's medication back to the facility. The facility received R1's prescription medication from the responsible party who dropped it off to them. Per record review, R1 didn't miss any medication. Resident's identification, name and medication information, was not kept confidential as required, Resident's prescribed medication was not kept secured, centrally stored, ensuring "all individuals" that don't handle facility resident medications, don't have access to the medications.
Continued on LIC9099C... |
| Substantiated | Estimated Days of Completion: |
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NARRATIVE |
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32 | These deficiencies will be cited, see the following:
87465 (h)(2) Incidental Medical & Dental Care-The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication, see LIC9099D
87468.2(a)(2) Additional Personal Rights of Residents in Privately Operated Facilities- To have their records and personal information remain confidential and to approve their release, except as authorized by law, see LIC9099D
Based on resident record reviews, staff interviews, photo, information obtained from interview(s) with other parties, the allegations of "facility staff mismanaged residents' medications, and resident's medication information was not kept confidential" are Substantiated.
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.
Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed.
Appeal Rights Given.
Exit interview conducted with the Administrator Janna O'Sullivan. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Request Denied
Type A
12/21/2023
Section Cited
CCR
87465(h)(2) | 1
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7 | 87465 (h)(2) Incidental Medical & Dental Care- Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by: | 1
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7 | CLEARED-LICENSEE HAD AN IN-SERVICE TRAINING CONDUCTED WITH ALL MEDICATION STAFF THAT ASSIST RESIDENTS WITH MEDICATIONS. ADMINSITRATOR PROVIDED PROOF OF TRAINING THAT WAS DONE AFTER THE MEDICATION INCIDENT OCCURRED. |
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14 | LPA's record reviews, and interviews, R1 had a prescription medication go out of the community with R2's medications who had moved out of the facility. R2's responsible party contacted the facility and returned R1's medication. The medication was not kept secured and inaccessible to all others that don't and/or shouldn't have access to the medications. This is an immediate risk to the health and safety of residents in care, and a risk to residents personal rights. | 8
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Deficiency Dismissed
Type A
12/21/2023
Section Cited
CCR
87468.2(A)(2) | 1
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7 | 87468.2(a)(2) Additional Personal Rights of Residents in Privately Operated Facilities- To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not met as evidenced by: | 1
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7 | Licensee to ensure that all resident's medication records, personal information, medical information, etc, are kept private and confidential as required. Licensee to hold an in-service with all medication staff regarding ensuring Personal rights of all resident's in care., ensuring resident's personal/private |
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14 | R1 had a prescription medication go out of the community with another resident's, R2, medications who had moved out of the facility. R1's identification, their medication pills, name and medication information, was not kept confidential as required. This is an immediate risk to residents health and safety, and to resident's personal rights. | 8
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14 | medical/medication information stays confidential at all times, during all policy and procedures of the facility.
POC due 12/21/23.
Proof of training due by 12/29/23. |