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, and record review, the licensee did not comply with the section cited above in 2 out of 2 residents in care by not ensuring, the MARS was initial stating the medication was issued, PM medication was already initial and haven't been dispensed, and if the resident receives an AM, NOON, and PM dose the initial appeared once or only twice. There was not an initial for each dose given or an explanation for the missing initial which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/18/2026 Plan of Correction Administrator agrees to conduct a training with all staff regarding common medication errors and how to avoid such errors. Administrator will submit a statement of understanding acknowledging understanding of the regulation cited and proof of training to LPA by POC due date. Training is due July 8, 2026. The statement of understanding is due by 6/18/2026.
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(a)(6)
- Regulation authority
- CCR
What the official deficiency says
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. 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 2 residents was missing the centrally stored medication log and medication that was stored was missing on the log which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/01/2026 Plan of Correction Administrator agrees to update the Centrally Store log and MARS to ensure the match and all medication stored is accounted for. Administrator will review, acknowledge and submit a statement of understanding for the regulation cited. Administrator will complete a training for all staff regarding the proper procedure on medication storage, centrally stored medication log, and maintaining the ledger. Administrator will submit proof of training to LPA by POC due date.