Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(h)(4)
- Regulation authority
- CCR
What the official deficiency says
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above. Resident #3’s (R3) Centrally Stored Medication and Destruction Record (LIC 622) was missing documentation for the month of October. Resident #4’s (R4) medication records were inconsistent. Additionally, Resident #6’s (R6) medication records were incomplete. This poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/15/2025 Plan of Correction Administrator will provide a complete copy of Centrally Stored Medication and Destruction Record (LIC 622) for R3, R4 and R6 by the POC date.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87456(a)(2)
- Regulation authority
- CCR
What the official deficiency says
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above. Resident #5’s (R5) and Resident #6s (R6) files were missing Preplacement Appraisal (LIC 603). This poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/15/2025 Plan of Correction Administrator will provide pre-admission appraisals for R5 and R6 by the POC date
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87458(a)
- Regulation authority
- CCR
What the official deficiency says
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above. Resident #5’s (R5) file was missing Medical Assessment (LIC 602A) which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/15/2025 Plan of Correction Administrator will provide LIC 602A for R5 by the POC date.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87507(c)
- Regulation authority
- CCR
What the official deficiency says
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review the licensee did not comply with the section cited above. Resident #6’s (R6) Admission Agreement was incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/15/2025 Plan of Correction Administrator will provide copy of the R6 Admission Agreement by the POC date.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87608(a)(5)(A)
- Regulation authority
- CCR
What the official deficiency says
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above. Resident #1 (R1) had full bedrails and was not receiving hospice services which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/15/2025 Plan of Correction Administrator removed immediately the bedrails.
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(i)
- Regulation authority
- CCR
What the official deficiency says
Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview the licensee did not comply with the section cited above. LPA observed expired medications, staff medications, and medications belonging to former residents. This poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/15/2025 Plan of Correction The administrator immediately removed all expired, staff, and former residents' medications. Administrator shall write a letter of understanding this regulation and properly destroy expired medications.