Facility Evaluation Report

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit to follow up on observations during a complaint investigation visit conducted on 9/2/25. LPA met with Stephanie Funderburg and explained the reason for the visit.

On 9/2/25 LPA Flores conducted a medication review during the review LPA reviewed medication list for the following residents and did not observed the medications available at the time of the visit:

Resident #1(R1) On 9/2/25 LPA did not observed Hydrocodone listed as needed. On 9/19/25 a physician's order dated: 8/21/25 notes the medication was prescribed for 7 days only.

Resident #2(R2) On 9/2/25 LPA did not observed Senna 8.6mg routine medication, Acetaminophen 325mg, and Oxycodone 5mg as needed medications. On 9/19/25 there are no discontinued orders.

Resident #3(R3) On 9/2/25 LPA did not observed Acetaminophen 325mg prescribed as needed. On 9/12/25 LPA Flores received a picture of the bubble pack medication with original Rx date: 12/18/24.

LPA interviewed R1-R3, residents stated they have not needed to ask for the medication. One resident refused to talk to LPA.

A deficiency is being cited today under Title 22 Regulations.

Exit interview was conducted and a copy of this report was provided.