Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
08/18/2023
Section Cited
CCR
87465(c)(1)
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7 | Incidental Medical and Dental Care: 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
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7 | Licensee will contact the physicians who prescribed the PRN medications and obtain signed PRN letters that indicate if the resident is able or unable to determine their own need for PRN medications and specify the PRN medication or if their doctor needs to be contacted prior to administering the |
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14 | permitted to assist the resident if following conditions are met: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation. All residents are prescribed PRNs and no PRN authorization letters were on file. This poses a danger to residents in care | 8
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14 | PRN medication by 8/18/23. Evidence will be submitted to LPA Yee by 8/18/23 |
Type B
08/18/2023
Section Cited
CCR87465(a)(6)
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7 | Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
When requested by the prescribing | 1
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7 | The Licensee will ensure that medications dispensed to residents are recorded on the MAR log daily to ensure that medication errors do not occur. Licensee will provide medication training to staff and provide copies of training logs to LPA by 8/18/23 |
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14 | physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. LPA observed that the MAR logs for August 2023 were not completed from 8/7/23-8/11/23. Per staff, medications were dispensed. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
08/18/2023
Section Cited
CCR
87465(e)
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7 | Incidental Dental and Medical Care -For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. | 1
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7 | Licensee will contact the doctor prescribing the medications and obtain a copy of the physicians order for all centrally stored medications and retain in each resident's file. The licensee will self certify that all physicians orders have been obtained and available for review by 8/18/23 |
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14 | Both the physician's order and the label shall contain at least all of the following information. 1)The specific symptoms which indicate the need for the use of the medication.(2) The exact dosage.(3) The minimum number of hours between doses.(4)The maximum number of doses allowed in each 24-hour period. The facility does not have any physician's orders on file | 8
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Type B
08/18/2023
Section Cited
CCR87217(g)
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7 | Safeguards for Resident Cash, Personal Property, and Valuables:Each licensee shall maintain adequate safeguards and accurate records of cash resources and valuables entrusted to his care, including, but not limited to the following: Records of residents' cash resources maintained
as a drawing account shall include a ledger
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7 | Licensee will review the P & I Ledgers, receipts and all transactions to determine the accurate balances in each of the residents P& I account. Licensee will provide a copy of the reconciled P & I ledgers to LPA by 8/18/23 |
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14 | accounting (columns for income, disbursements and balance) for each resident, and supporting receipts filed in chronological order. Each accounting shall be kept current. Facility records are unclear as to the P &I balances for R2, R5 & R6. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
08/12/2023
Section Cited
HSC
1569.69(a)(2)
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7 | Employees assisting residents with self-administration of medication; training requirements: a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets the following training requirements | 1
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7 | Licenseer will submit a plan of action as to how medication assistance will be provided to residents until all staff have received medication training by 8/12/23 Licensee/administrator will submit the credentials of the vendor and the scheduled training date and proof of training will need to be submitted by |
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14 | ) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete six hours of initial training. This training shall consist of two hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and four hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. Lorna Montemayor has not been provided with any medication training. | 8
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14 | 8/18/23. All staff training records will be maintained in the staffs file |
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