Kirkwood Orange

Based on records reviewed, two out of six resident files reviewed included an outdated medical assessment for residents with an indication of dementia. This poses/posed a potential health, safety or personal rights risk to persons in care.

Give PRN medication by physician order

87465 Incidental Medical and Dental Care(c) If the resident's physician has stated in writing...(2) Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidence by: Based on LPA's interviews, review of documents obtained and observations, resident 1 (R1) had a medication error due to being given double the dose of the prescribed medication. This poses a potential health and safety risk to residents in care.

Report specified resident events within seven days

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence.This requirement is not met as evidence by: Based on LPA's interviews, review of documents obtained and observations, facility failed to report incidents to the licensing department within seven days. Per documentation review, the 9 residents who missed their medications occurred on 12/16/23, but was reported to the department on 12/29/23.This poses a potential health and safety risk to residents in care.

Give PRN medication by physician order

87465 Incidental Medical and Dental Care(c) If the resident's physician has stated in writing...(2) Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidence by: Based on LPA's interviews, review of documents obtained and observations, facility admitted to not giving a total of 9 residents their medications per psychian's directions, and was observed via medication log and incident report that medications were missed in December 2023.This poses an immediate health and safety risk to residents in care.

Care and supervision as defined by statute and rules

87464 Basic Services(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This standard is not met as evidenced by:Based on observation, record reviews and interviews, facility did not comply with the section cited above. Facility administrator confirmed with LPA that resident did sustain a fracture while in care and that staff on duty failed to report it.