F 0554
Allow residents to self-administer drugs if determined clinically appropriate.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure the licensed nurse completed an
assessment for self-administration of medications for one of three residents (Resident 2).
Residents Affected - Few
This failure had the potential for unsafe self-administration of medications, duplication of medications, and
interactions with other medications for Resident 2.
Findings:
On February 10, 2023, at 11:45 a.m., an announced visit to the facility was conducted to investigate an
allegation of abuse.
On February 10, 2023, at 1:25 p.m., a concurrent observation and interview were conducted with Resident
2. Resident 2 stated he was purchasing his own supplies during his stay in the facility. Resident 2 opened
the top drawer of the dresser and took out various medications. Resident 2 stated he has Benadryl cream
for bites on his legs, Tums tablets for his heartburn, Benadryl tablets (anti-allergy medication), and Pepto
Bismol liquid (for heartburn).
On February 14, 2023, at 12:20 p.m., an interview with Resident 2 was conducted. Resident 2 stated he
ordered his medications online and have them delivered. Resident 2 further stated, he used the Pepto
Bismol, Benadryl, Tums, and cream on himself when needed. Resident 2 stated the facility did not have
stock of these medications when he requested them. Resident 2 stated, the facility knew he had these
medications.
Review of Resident 2's record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses
which included Parkinson's Disease (a disorder of the central nervous system), Seizures (temporary
abnormalities in muscles and movement), Gastro-Esophageal Reflux Disease (acid or bile in the stomach
irritates the food pipe).
Further review of Resident 2's record indicated no documentation that the licensed nurse completed an
assessment for Resident 2 for self-administration of medications.
On February 14, 2023, at 1 p.m., the Director of Nursing (DON) was interviewed. She stated the resident
could not keep medications at bedside without a self-administration of medication assessment.
On February 14, 2023, at 1:30 p.m., a concurrent interview and record review with the DON was
conducted. The DON stated, Resident 2 did not have a self-administration assessment completed. The
DON further stated the resident could not keep medications at bedside.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
055042
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055042
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alta Vista Healthcare & Wellness Centre
9020 Garfield Street
Riverside, CA 92503
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0554
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On February 14, 2023, at 2:30 p.m., an interview with the Licensed Vocational Nurse (LVN) was conducted.
The LVN stated, Resident 2 had no orders for Tums or cream for Resident 2's bites on his legs. The LVN
further stated, he was not aware Resident 2 kept medications in his dresser to use when necessary.
On February 14, 2023, at 3:15 p.m., an observation of the LVN was conducted. The LVN went to Resident
2's room, removed the medications from the resident's drawer, and brought them to the nurse's station. The
LVN removed one bottle of Pink Bismuth Subsalicylate (Pepto Bismol), one bottle of Tum's chewable
tablets, and one bottle of Diphenhydramine (Benadryl) tablets.
A review of the facility's policy and procedure titled Medication-Self Administration, dated January 1, 2012,
indicated .To provide residents with the opportunity to self-administer medications determined by the
attending physician and the Interdisciplinary Team (IDT) .the IDT will assess the resident's cognitive,
physical and visual ability to carry out this responsibility based on a review of an assessment by a licensed
nurse .the Assessment for Self-Administration of Medications .The resident may not begin
self-administration of medications prior to the approval of the IDT and the Attending Physician .The
Attending Physician must provide a written order permitting the resident to self-administer medications .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055042
If continuation sheet
Page 2 of 2
