Facility Evaluation Report

On 8/22/2024 Licensing Program Analyst (LPA) B. Miranda arrived unannounced at the facility to conduct a Continual Annual Inspection. LPA introduced herself and explained the reason for the visit. LPA met with Licensee Nerissa Ramos .

When LPA entered the facility the auditory alarm was not on, facility serves dementia residents. On the 8/7/2024 visit auditory alarms were also not on. Smoke detectors and alarms were serviced on 8/19/2024 by Tri-County Fire Protection, and passed inspection. Carbon monoxide detectors were tested today 8/22/2024 and are in working condition.

On 8/7/2024 LPA observed staff (S1) was not properly cleared and was required to leave the facility. Civil Penalty.

LPA reviewed R1's medications, and observed the following issues:

Tramadol HCL 50 MG Tablet- Marked on Centrally Stored Log and prescription as starting on 8/15/2024, the count was off, narcotics log has 3 different entries for two for 8/15/2024 & one for 8/16/2024.

Lactulose 10 GM/15 ML Centrally Stored Medication Log has medication start date of 8/9/2024, medication label was marked as staring on 8/15/2024.

Docusate Sodium 50 MG/5 ML was labeled on the bottle with a start date of 7/24/2024, logged on the Centrally Stored Log as starting 8/9/2024.

Guaifenesin 100 MG/5ML (PRN) RX number was logged incorrectly on the Centrally Stored Medication Log.

Facility has a licensed capacity for 40, and has not had consultant pharmacist or nurse review the medication management program.

Deficiencies were noted and citations were issued under Title 22.

Licensee will follow-up with manufacture date for salad dressing and policy for medication destruction log. Due 9/6/2024

Exit interview was conducted and a copy of this report LIC809, LIC809D, LIC421BG, and appeal rights were provided to was emailed to Licensee Nerissa Ramos