Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
11/22/2022
Section Cited
CCR
87465(c)(2)
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7 | 87465(c)(2) Once ordered by the physician, nonprescription PRN medications shall be given in accordance with the physician’s directions. | 1
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7 | By 11/22/2022 the Administrator shall evaluate the facility's medication distribution practices and submit a revised program plan on medication management to avoid any further medication errors. Further, additional medication training shall be completed by staff who handle medication. |
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14 | This requirement was not meet as evidenced by. LPA Received SIR for R1 being given an extra dose of medication. | 8
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Type A
11/22/2022
Section Cited
CCR87465(d)(1-3)
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7 | If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. | 1
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7 | Licensee shall submit plan on when an in-service to medication staff will be completed. Completion shall be submitted with proof of attendance to CCL by 11/22/22,
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14 | This requirement is not met as evidenced by: Records reviewed and interviews with the Administrator confirmed that the facility did not have the Physician identify the abilities of R1 to determine her needs for PRN medication as a result the facility administered Seroquel twice as a PRN which was not how the PRN was written. The facility does not have a current list of PRN medications sign by the Physician as to R1’s ability to determine if the medications are needed and whether are not the Physician needed to be contacted prior to or after | 8
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14 | as well as updating the resident files to include a signed PRN letter for each resident that takes a PRN with the wishes of the assigning Physician |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Deficiency Dismissed
Type B
12/03/2022
Section Cited
CCR
87211(a)(1)(d)
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7 | Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. | 1
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7 | Administrator will review Title 22 Regulations Section 87211 and have an In-service training with all Staff regarding Reporting Requirements. Administrator will submit a written plan ensuring that incidents are reported to the CCL office as required according to the Regulation. Signatures of all |
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14 | This requirement was not meet as evidenced by records review LPA'S reviewed R1'S file and found they were being treated for rash that was later identified as scabies, (SIR) serious incident report was not sent to CCL until 10/04/2022. Rash first identified in June 30th 2022. This poses an immediate health and safety risk to residents in care. | 8
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14 | Staff from the training must be submitted to CCL after training is complete. The plan is due by the POC date of 12/03/22. |
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