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 in two (2) out of three (3) residents in care by not ensuring that the current centrally stored log had a list of all medications being dispensed. LPA observed the log for the month of November was missing medication that had been prescribed in prior months such as January, August, and October, but was not on the current log for November centrally stored medication for two (2) out of three (3) residents which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/12/2025 Plan of Correction Administrator agrees to conduct a routine audit of the centrally stored medication log and ensure all medications are listed for the current month. Administrator agrees to conduct a training with all staff that assist with medication and submit a training log of all participants and a statement of understand of the regulation cited by POC due to LPA.
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(d)(3)
- Regulation authority
- CCR
What the official deficiency says
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in three (3) out of three (3) residents in care by not maintain a MARS log, signing and dated when the medication was being dispensed which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/12/2025 Plan of Correction Administrator agree to complete a training, a statement of understanding, and start maintaining a log of PRN medication that is dispensed to residents in care by POC due to LPA.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(a)
- Regulation authority
- CCR
What the official deficiency says
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in three (3) out of three (3) residents in care by not ensuring that the facility maintained a Needs and Service Plan/ Appraisal report annually to dementia, hospice, bedridden residents or for changes in condition which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/12/2025 Plan of Correction Administrator agrees to complete a Needs and Service plan for all residents in care and maintain this review annually. Administrator will notified LPA upon completion by POC due date.