Facility Evaluation Report

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:44 AM. LPA met with facility staff member Emma Elazyan (S1) who contacted the facility administrator Emma Avetisyan. The Administrator informed LPA that they were unable to come to the facility at the time of the visit. Facility representative Meri Tarposhyan (S2) arrived to the facility at approximately 11:50 AM. Entrance interview was conducted and the reason for the visit was explained. The following was observed:

MEDICATION REVIEW: Medication review began at 09:55 AM. Medications for six (6) of six (6) residents were observed. LPA observed Resident #1’s (R1) medications to be improperly documented on their centrally stored medication and destruction record sheet (CSMDR). LPA informed S2 who stated that the medications arrived at the facility at approximately 08:00 PM the previous night (03/17/2026) and had not yet been documented on the CSMDR. Additionally, LPA observed one (1) medication from Resident #2 (R2) to not be logged appropriately on their CSMDR. During medication review LPA observed a total of twenty three (23) medications across all six (6) residents to have errors in the medication count. LPA and S2 observed the CSMDRs for all six (6) residents and confirmed that the amount of medications remaining in the bottles did not match the amount of medications that should be left based on the recorded start date and medication administration instructions. S2 was unable to provide LPA with a justification as to why the medication count was incorrect. This deficiency was cited under a complaint report for this facility. No deficiency for this violation is being generated under this report.