Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(4)
- Regulation authority
- CCR
What the official deficiency says
(4) The licensee shall assist residents with self-administered medications as needed. 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 5 residents had missed doses of medication which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction Administrator agrees to submit a statement of intent by due date to conduct medication in-service training and submit records of training when completed.
Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87608(a)(5)(B)
- Regulation authority
- CCR
What the official deficiency says
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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 four out of 5 residents had full bed rails without a physician order in hospice care plan which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction Administrator agrees to remove full bed rails until a full bed rail physician order is in place.
Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87633(b)(4)
- Regulation authority
- CCR
What the official deficiency says
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (4) A description of the licensee's area of responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident's physician, and the resident's responsible person(s), if any. This description shall include the type and frequency of the tasks to be performed 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 5 out of 5 residents hospice care plan did not document facility staff duties regarding care which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction Administrator agrees to develop a needs and service plan/ care plan regarding facility staff duties for care and submit documentation to CCLD by due date.
Admission, assessment, and evictionType A
- Official classification
- Type A
- Official code
- 87458(a)
- Regulation authority
- CCR
What the official deficiency says
87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 5 residents did not have a medical assessment on file which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction Administrator agrees to have medical assessments completed and submit them to CCLD by due date
Medication handling and storageType B
- Official classification
- Type B
- 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 5 residents PRN medication was not logged or was logged without the required information which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/06/2026 Plan of Correction Administrator agrees to provide a in-service training regarding PRN medication regulations and submit records of training and copies of corrected PRN Medication Logs by due date.