Facility Evaluation Report

On this day Licensing Program Analyst (LPA) made an unannounced visit for a case management in conjuction with complaint control 22-AS-20250102131745.

It was alleged that Resident 1 (R1) was administered unauthorized medications.

Per review of R1's medical records the facility received a fax from R1's current physician requesting the medication of Oxybutynin to be tapered off and then discontinued, the fax was received on 07/19/2023. Per review of medication administration records (MAR) Oxybutynin was tapered off and eventually discontinued in August of 2023, review of December 2023 MAR the medication is refilled by R1's former physician and continued to be given to R1 until August 14th 2024.

Based on interview with Health Services Director Marties Meneses she started at the community around August 2023. Health Services Director stated the order was followed but in December 2023, someone on her staff found the original order of Oxybutynin from R1's former physician dated 3/16/2023. Heath Services Director stated that once it was brought to her attention that an order was received on 07/19/2023 by R1's current physician then the MAR was updated. Health Services Director stated the order from 07/19/2023 was filed by previous Health Services Director and was not located until August 2024. Per interview with Health Services Director the issue was not reported to the Department.

Therefore based on interviews and records reviewed the following is being cited per Title 22.

An exit interview was conducted and a copy was provided to facility representative.