Follow-up·October 25, 2023

On 10/25/2023, at 3:00pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived at the facility unannounced to conduct a case management visit. LPAs met with Administrator Caleb Summerhays and stated the purpose of this visit. The Department received a fax from City Creek on 8/22/23 regarding Resident_1’s (R1) blood pressure medication. Per review of the faxed document indicated that R1 was taking a prescribed blood pressure medication requiring blood pressure reading prior to self-administration. Further review of the faxed document indicated that it was addressed to R1’s physician in which the facility requesting for the prescription order to change without the need to take blood pressure reading prior to self-administration. Interview with Staff_1 (S1) on 8/30/23 reveal that the fax was sent to the Department accidentally and it was meant to be faxed to R1’s physician. Per interview with S1 it was also revealed that during their recent medication inventory of all facility residents’ medication, staff discovered an oversight on R1’s medication requiring a vital sign reading prior to self-administration. S1 informed LPAs that med techs who are not appropriately skilled professionals have been assisting R1 with blood pressure medication and taking R1’s blood pressure readings. LPAs also conducted medication audits and observed medication passing of random residents in care on 8/30/23. Based on records reviews and interviews, there is a preponderance of evidence to conclude that staff inappropriately assisted R1 with self-administration of medications. Per California Code of Regulations Title 22, Division 6, Chapter 8) citations for deficiencies can be found on the LIC 809-D. An immediate civil penalty of $250 is issued in addition to citation due to repeat violation. Failure to correct deficiencies may result in additional civil penalties. An exit interview was conducted with Administrator Caleb Summerhays and a copy of this report and appeal rights were provided.