Facility Evaluation Report

Licensing Program Analyst (LPA) Rankin arrived at 12:01 p.m. to continue the 1-year annual visit to the facility above. LPA met with Megan Drap, Business Office Director and Designee and explained the purpose of the visit. LPA additionally started investigating new complaint # 29-AS-20260708123103.

Medication review not addressed during initial annual visit were discussed and a review of staff and resident records was done:

Incidental Medical & Dental: During annual visit on 7/8/26 LPA viewed all medications for the Assisted Living Community from approximately 10:25 am to 12:30 pm and found 5 residents a total of 8 medications that had expired from dates ranging in 2025 to 5/2026, 6 of the medications were found in the overflow supplies, 2 medications were located in the medication cart, a liquid PRN antacid that had expired 6/2025 and a PRN bubble pack of Senna that expired 5/13/26 and the order had been discontinued by the doctor on 6/26/25. One of the expired medications belonged to a resident who passed away in 2025. Two of the medications had discontinue orders and should not have been kept in the resident supply of medications. Citation referencing requirements for destroying medications as required was cited.

Staffing, Personnel Records: The facility currently employes 57 staff and 1 Administrator. LPA reviewed 12 staff files. Files reviewed had current 1st Aid/CPR, Health screening with TB results, applications and other required documents.