Medication handling and storageType A
- Official classification
- Type A
- 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 1 out of 3 residents in care by not ensuring and maintaining the centrally store medication log. The month of November centrally stored log was missing medications that were prescribed from previous months. Administrator had to locate the medications listed on a centrally stored log from the prior months: August, September, and October which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/18/2025 Plan of Correction Administrator agrees to start maintaining a monthly log of all centrally stored medication and conduct a training with all staff on maintaining the log. Administrator will complete a statement of understanding and training log of all participant to be submitted to LPA by POC due date.
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(b)
- Regulation authority
- CCR
What the official deficiency says
(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. 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 1 out of 3 residents in care by not ensuring was not dispensed according to the doctors order. The bubble pack was stated to have begin on 10/22/2025 and as of today the bubble pack should only have 3 pill in the pack. LPA observed the medication pack had four or more pills remaining in the pack which indicates the medication was not dispensed as prescribed by the doctor and was missed. There were not any note explaining the extra pills remaining in the bubble pack. This was observed with four different medications from the centrally stored medication log which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/17/2025 Plan of Correction Administrator agrees to conduct a training with all staff regarding medication error and proper dispensing of medications. Administrator will complete a statement of understanding and training log of all participant to be submitted to LPA by POC due date.