COUNTRY OAKS MANOR

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the LIcensee did not ensure that (R1) was administered scheduled medications, from approximately 4/28/23 through 5/9/23 (morning), while waiting for the medications to be delivered, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator agree to read regulation 87465 and submit a signed statement of its understanding and also to consider using a Medication Administration Record (MAR) to log every dosage that is administered. Documentation to be submitted to the Dept by 9/11/23 by email/Fax.

Deadline recorded: Sep 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(i)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (i) 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: Based on interview, the Licensee did not document an ending medication inventory and obtain a signature when (R1's) medications were picked up on 5/17/23. The medications picked up on 5/9/23 were not logged on the LIC622-

Official plan of correction

Licensee/Administrator agree to read regulation 87465 and submit a signed statement of its understanding. Admin agrees to review all current residents' files and ensure that all medication is written on the LIC622.

Deadline recorded: Sep 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as LPA observed multiple sharps to be in a drawer with a non-functioning lock, unsecured medications in resident (R1) room and in a cabinet near the kitchen, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/07/2022 Plan of Correction Administrator immediately removed the unlocked sharps and medications and placed them in a locked area. Administrator agrees to install a functioning lock on a kitchen drawer to store sharps in and to always store medications in a locked area with the rest of the medications. Documentation (photo) of working lock to be sent to the Department (email/fax) by 11/7/2022.

Official classification

Type B

Official code

87467(a)(1)

Regulation authority

CCR

What the official deficiency says

87467 Resident Participation in Decision making (a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility. (1) At a minimum the written record shall include the date of the meeting, name of individuals who participated and their relationship to the resident, and the agreed-upon services to be provided to the resident. 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 (3) of (5) resident files which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/21/2022 Plan of Correction Administrator agrees to complete a care plan (i.e. LIC625) for each resident, detailing the care/services the facility will provide. Copies of each completed care plan to be provided to the Department by fax/email by 11/21/2022.