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Inspection visit

Complaint

KIRKWOOD ORANGELicense 3060058352 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

It was alleged that facility did not follow reporting requirements of missed medications to the department. 9 out of 9 resident interviews were unable to provide additional information regarding this allegation. 2 out of the 2 staff interviews corroborated with the allegation by stating that the executive director present during December 2023, did not report the missed medications to the department due to the facility undergoing changes in management and staffing, which led to the failure of reporting to the department. Per documentation review, a total of 9 residents missed their medications on 12/16/23, and reported it to the department thirteen days later on 12/29/23. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, the preponderance of evidence standard has been met, therefore the allegations are SUBSTANTIATED. For this visit, citations were issued. An exit interview was conducted with BOM Islas. A copy of this report was explained, and appeal rights were provided during the visit.

Citations

2 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87211(a)(1)Type B

    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.

  • 87465(c)(2)Type A

    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.

FAQ · About this visit

Common questions about this visit

What happened during the March 20, 2024 inspection of KIRKWOOD ORANGE?

This was a complaint inspection of KIRKWOOD ORANGE on March 20, 2024. 2 citations were issued: 1 Type A (serious) and 1 Type B.

Were any citations issued to KIRKWOOD ORANGE on March 20, 2024?

Yes, 2 citations were issued (1 Type A, 1 Type B). The first citation was for: "87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports...(1) A written report ..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.