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Inspection visit

Incident investigation

SANTA MARIA TERRACELicense 4258500251 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Olson conducted a Case Management - Incident visit to issue deficiencies on a medication error the facility self reported. LPA met with Administrator and Wellness Director over the phone and explained the purpose of the visit. CCL received an incident report on 01/27/24 stating that on 01/21/24 Staff 1 (S1) prepared 2 different medications at the same time and took the wrong one to Resident 1 (R1). R1 was given medications that could decrease respirations, resident was informed and the doctor was called immediately. R1 was given the option to go to the ER but they declined so care staff monitored R1 in their room, one-to-one for respiratory depression until 4am and then twice per shift from 1/22/24 through 1/24/24. Staff 1 was written up and retrained on the 7 resident rights by Wellness Director. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). A civil penalty for a repeat violation for $250 was assessed. An exit interview was conducted, a copy of the report, Civil Penalty, and appeal rights were issued.

Citations

4 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.

  • 87465(a)(4)Type A

    87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply in the section sited above when staff did not properly assist residents with medications and issued the incorrect dose which posed an immediate health and safety risk to residents in care.

  • 87411(a)Type B

    87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement was not met as evidenced by: Based on interviews, the licensee did not comply in the section sited above when staff were not sufficient in numbers at all times to meet resident needs, which posed a potential health and safety risk to residents in care.

  • 87464(f)(4)Type B

    87464 Basic Services (f)(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications... This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply in the section sited above when staff did not properly assist resident with showers or have a system to make up missed showers which posed a potential health and safety risk to residents in care.

  • 87507(c)Type B

    87507 Admission Agreement (C) Any fee that is charged prior to or after admission, shall be clearly specified.This requirement was not met as evidenced by: Based on interviews, the licensee did not comply in the section sited above when staff did took 4 months to agree on a refunded shower amount, which posed a potential health and safety risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the February 2, 2024 inspection of SANTA MARIA TERRACE?

This was a other inspection of SANTA MARIA TERRACE on February 2, 2024. 1 citation were issued: 1 Type A (serious).

Were any citations issued to SANTA MARIA TERRACE on February 2, 2024?

Yes, 1 citation was issued (1 Type A, 0 Type B). The first citation was for: "87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each fac..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

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.