Facility Evaluation Report

On 5/29/2025, at 8:15 AM, Licensing Program Analyst (LPA) Bernadette Alle n conducted an unannounced visit to deliver findings for the alleged allegations for complaint Contr ol N umber 11-AS-20241217143234. LPA identified herself and met Joel Niblett- Administrator who was informed of the purpose of the visit.

O n May 12, 2025, the LPA conducted a random audit of the Medication Administration Record (MAR) for Residents 1 through 4 (R1–R4). During the audit, LPA observed that R1’s medications appeared to have been dispensed; however, staff were unable to provide the corresponding MAR for review. Additionally, LPA noted that R2’s medications were recorded as dispensed on May 2 and May 12, 2025, but were still in their original packaging. Marcus Falanai resident care coordinator, was unable to confirm whether R2’s medications had actually been dispensed. Meanwhile, LPA verified that R3 and R4’s medications had been dispensed and signed off by a medtech. This violation poses a potential health, safety, or personal rights risk to residents in care and a citation was issued.

On May 29, 2025, LPA conducted interviews, observations and reviewed the LIC500, noting that some staff members are listed as caregivers and medtechs. Interviews with S1, S2, S3, and S8 confirmed that they hold certifications but were unable to provide current copies. They also stated that they have registered for re-certification through Elite Medical Academy. Additionally, staff members S4, S5, and S6 have not been observed dispensing medications. Joel was informed that the absence of current certification documentation for staff members presents a potential health, safety, and personal rights risk to residents in care. As a result, a citation will be issued for failure to maintain complete and up-to-date staff files for review at the time of the visit.