Facility Evaluation Report

On 08/04/2025 Licensing Program Analyst (LPA) Evelin Rios conducted an announced Case Management - Deficiencies visit in conjunction with complaint control #31-AS-20250114101006,. During the investigation on 01/22/2025 LPAs Evelin Rios and Nadia Shahbazian conducted a medication review and made observations of the pills in the bottles. LPA's observation of two different PM medications revealed each bottle had one pill that appeared a different color and size then other pills in the bottle. According to staff interviews the older medication was poured into the new bottles. Based on the description on the older bottle the medication was the same. Staff immediately removed the pills that did not resemble the others and sit it aside for destruction. On 08/04/2025 according to the administrator the facility has conducted medication training since visit on 01/22/2025.

The administrator shall maintain all medications in its original containers when administered in the facility. Administrator provided all staff training regarding medication administration that was completed 02/26/2025 and certificates were submitted to LPA. POC cleared on today visit.

Deficiency cited (refer to LIC809D) Exit interview conducted, a copy of this report and Appeal Rights provided.