Facility Evaluation Report

Licensing Program Analysts (LPAs) Anna Bueno and Amber Coleman conducted an unannounced visit to the facility for the purpose of conducting a case management visit. In November 2022, CCL received two reports related to medication documentation. LPA's were greeted by staff member (S1) Sabrina Weddles who invited LPA's inside. LPA's and S1 discussed the purpose of the visit.S1 contacted Administrator on the phone during visit to answer LPA's questions.

R2's medication record indicated the resident is prescribed to have a medication administered three times a day. LPA observed that only 2 signatures per day were present. Administrator explained that the afternoon medication is PRN; which means R2 is given the medication when they ask for it. However, a review of the medication record shows that the medication is to be administered three times daily and no refusals were indicated from R2. Medication dispensed on 11/2/2022 shows eight tablets that were not administered. Additionally, for the dates 12/2/22 to 12/5/22 according to the records the medication was only given to R2 twice a day, missing the afternoon dosage.

This poses an immediate health and safety risk to the residents in care. Refer to LIC809-D for deficiency cited. A copy of this report, LIC809-D and appeal rights were proved to facility representative.