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Official classification

Type B

Official code

87465(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (2) The exact dosage. 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. During a medication review, one resident did not have the correct dosage in one of their medication which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/29/2025 Plan of Correction Per discussion, administrator will contact resident's family member to obtain the correct medication. Administrator will submit proof of the correct medication to the Department by POC due date.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observation, licensee did not comply with the regulation noted above. It was observed that 3 medications were stored in the kitchen refrigerator. This poses an immediate health and safety

Official plan of correction

Licensee to submit a written statement of understanding of the regulation cited and submit statement to the Department by POC due date. Per discussion with Licensee, they have agreed to provide staff training on proper medication storage. Licensee will submit completed training by end of day on 10/25/24. Per Licensee they will obtain a locked box and will store the locked box in the garage refrigerator.

Deadline recorded: Oct 16, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on observation, licensee did not comply with the regulation noted above. During inspection of one bathroom, LPA observed cleaning supplies on the floor and on top of the toilet seat cover. This poses an immediate health and safety

Official plan of correction

Licensee to submit a written statement of understanding of the regulation cited and submit statement to the Department by POC due date. Per discussion with Licensee, they have agreed to provide staff training on proper storage of dangerous items and chemicals. Licensee will submit completed training by end of day on 10/25/24.

Deadline recorded: Oct 16, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal... (1) Nonambulatory persons. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the regulation noted above. It was discovered that the room fire cleared as " staff " room on the facility sketch is being used as a resident room by non-ambulatory resident during this visit. This poses an immediate health and safety risk to residents in care.

Official plan of correction

LPA submitted form STD 850 to the local fire department on 5/3/24. Local fire marshal conducted an initial visit and suggested for an installation of a ramp at the exit door. Licensee to install a ramp at the exit door of the said bedroom and will send photo evidence to the Department once completed. Licensee to submit a written statement of understanding of the regulation CCR 87202 to the Department by POC due date.

Deadline recorded: May 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87611(a)

Regulation authority

CCR

What the official deficiency says

87616 Exceptions for Health Conditions: (a) ... the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means. This is not met as evidenced by: Based on interviews and record review the Licensee did not ensure that a written request for an exception was sent to the Department for approval as soon as R1 started using a catheter. This poses an immediate, health, safety, and personal rights risks to persons in care.

Official plan of correction

Licensee has already submitted an exception request for catheter to the Department and awaiting for Department approval. Licensee to submit a statement of understanding of the regulation related to restricted/prohibited health conditions to the Department by the POC due date.

Deadline recorded: Mar 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

(d) The administrator shall have... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This is not met as evidenced by: Based on interview and record review, the licensee did not ensure that the facility obtained an exception request for R1's indwelling catheter as soon as R1 started using catheter.

Official plan of correction

The licensee shall provide a statement of understanding regarding the following regulation 87405(d)(2) to the Department by the POC date.

Deadline recorded: Mar 12, 2024. A deadline is not proof that correction was completed.