Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(c)(3)
- Regulation authority
- CCR
What the official deficiency says
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above in that the facility did not have the resident's medication administration record (MAR) for May 2026, which poses an immediate health, safety or personal rights risk to residents in care.
Official plan of correction
POC Due Date: 05/12/2026 Plan of Correction Administrator agreed to submit a copy of a completed medication administration record (MAR) for May 2026 for R1 to CCL/LPA by POC due date.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(c)
- Regulation authority
- HSC
What the official deficiency says
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 in that the facility has not conducted an emergency drill since May 2025 which poses/posed a potential health, safety or personal rights risk to residents in care.
Official plan of correction
POC Due Date: 05/18/2026 Plan of Correction Administrator shall nsure that emergency drill is conducted quarterly. Administrator will send a copy of the in service training log of the emergency drill to CCL/LPA by POC due date.