Medication handling and storageType A
- 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: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in 4 of 4 persons which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/23/2026 Plan of Correction LPA had Staff #1 lock medication in cabinet and LIcensee agrees to conduct outside source training to all staff and themselves regarding medciation storage.
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(h)(5)
- Regulation authority
- CCR
What the official deficiency says
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in 4 of 4 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/22/2026 Plan of Correction Licensee will immediately discontinue the practice of pre-pouring medications. Licensee will retrain all staff responsible for medication assistance and medication handling, ensuring medications are dispensed only from the original pharmacy container at the time of administration. Licensee will submit proof of staff retraining to LPA by the POC.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(e)(3)
- Regulation authority
- HSC
What the official deficiency says
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (3) A resident medication list for residents with centrally stored medications. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview , the licensee did not comply with the section cited above in 4 of 4 which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/22/2026 Plan of Correction Licensee will create and maintain a medication list for all residents with centrally stored medications, as required by HSC 1569.695(e)(3). Licensee will update resident files for the four affected residents. Licensee will submit copies of the completed medication lists to LPA by the POC Date
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(h)(1)
- Regulation authority
- CCR
What the official deficiency says
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 2 of 4 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/22/2026 Plan of Correction Licensee agreed to coordinate with responsible persons (RP) to ensure that R1 and R2 completes their annual routine physical/medical visit. (In cases where the RP refuses the annual visit, Licensee will document such refusal in writing.) Licensee agreed to send proof of completion to LPA, by the POC due date.