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32 | It was alleged that the facility staff did not dispense three (3) medications for resident #1 (R1). Investigation revealed that during medications review there was no resident file including the Centrally Stored Medication and Destruction Record (CSMDR) for R1 or any residents. LPA conducted a sample of three (3) resident medications and observed that one (1) out of three (3) medications were not issued as prescribed. R1 was not assisted with their prescribed medication for nine (9) days from the month of December when R1 was first admitted 12.24.2024. Three (3) out of eight (8) medication were observed for R1. At 12pm LPA interviewed staff #1 (S1) who stated staff #2 (S2) and staff #3 (S3) assist residents with their medications. S2 stated that they follow medication as prescribed. When asked why R1 missed nine (9) days of medication staff declined to say anything and just stared at LPA.
LPA requested medications training, however there was no documented training provided. LPA review the facility’s medications policy which state that the licensee will have "A record of currently prescribed medications, and an indication of whether the medication should be centrally stored." At 12:45 PM-1:10PM, LPA interview three (3) out of five (5) residents who were able to communicate. Interview revealed R1 and R3 are not aware of the medications they are taking and dispense time varies. Based on record review and interview obtained the allegation is SUBSTANTIATED. R1 was not assisted with medications for 9 days. Deficiency issued.
Allegation #2: Staff did not assist resident with mobility needs.
It was being alleged that facility staff does not assist residents with mobility needs. To investigate this allegation, LPA conducted a file for R1. LPA attempted to reviewed R1’s Admissions Agreement, Physicians report and Appraisal, however the Administrator had no records on file for any residents. There was no documented care plan to determine the residents needs and there was no documented training for staff related to any of the resident’s care.
LPA interviewed the Administrator and one (1) staff out of three (3). Staff interview revealed that R1 is bedridden and no assistance with mobility is provided. R1 is provided meals, room and board, medication assistance, and assistance with ADL's in their room. R1 is not assisted out of their bed to join other residents for dinner and or other activities. In addition, during interviews with other residents, it was determined that staff are not consistent with their assistance. Two (2) out of five (5) residents state that staff are not consistent in providing the following assistance of ADL's and medication management. During the visit LPA observed R1 staying at their room the whole time without any rotation or staff observation.
Based on observations, and interviews, the allegation is SUBSTANTIATED. Deficiency issued. Appeal rights given. Exit interview conducted. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
01/22/2025
Section Cited
CCR
87465(c)(2) | 1
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7 | Incidental Medical and Dental Care Services. Once ordered by the physician, nonprescription PRN medications shall be given in accordance with the physician’s directions. LPA observed that R1 medication has, | 1
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7 | The Administrator has agreed to the following: Administrator and staff will take state approved training on the regulation Prohibited Health Conditions. Submit training schedule with the vendors name. date of schedule. Upon completion submit the training material and staff sign in sheet.
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14 | discrepancies. This requirement is not met as evidenced by: Based on observation, residents medication bubble pack was full and unuse which disrupts the comfort and health of others which poses a potential health, safety and personal rights risk to clients in care. | 8
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Type B
01/20/2025
Section Cited
CCR
87705(c)(4) | 1
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7 | Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety... | 1
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7 | The Administrator has agreed to the following: All administrator and staff will take state approved training on the regulation Prohibited Health Conditions. Submit training schedule with the vendors name. date of schedule. Upon completion submit the training material and staff sign in sheet.
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14 | This requirement was not met, evidenced by, based on interviews, staff are inconsistance to provide assiatance to the residents. This poses as a potential health and safety risk to residents in care. | 8
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