Medication handling and storageType A
- Official classification
- Type A
- 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 LPA and Admin observation and interview, the licensee did not comply with the section cited above in that facility is pre-pouring medications, which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/27/2025 Plan of Correction Facility to submit LIC9098 self-certifying they will immediately cease pre-pouring medications, by plan of correction due date.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(f)
- Regulation authority
- CCR
What the official deficiency says
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin record review, the licensee did not comply with the section cited above in that S1, S2, S3, and S5 did not have TB clearance and S4 and S5 did not have Health Screens on file, which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/16/2025 Plan of Correction Facility to submit TB clearance for S1, S2, S3, and S5 and Health Screens for S4, and S5 by plan of correction due date.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87458(c)(1)(A)
- Regulation authority
- CCR
What the official deficiency says
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin record review, the licensee did not comply with the section cited above in that R2 did not have TB clearance on file, which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/16/2025 Plan of Correction Facility to submit to CCL proof of TB clearance for R2 by plan of correction due date.
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 LPA and Admin record review, the licensee did not comply with the section cited above in that R1 and R3 did not have a current appraisal/pre-appraisal on file, which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/09/2025 Plan of Correction Facility to submit to CCL completed appraisals for R1 and R3 by plan of correction due date. Appraisals to be signed by resident/resident's responsible party. If responsible party cannot sign, proof of delviery to repsonsible party must also be submitted.