Facility Evaluation Report

Licensing Program Analyst (LPA) Melisa Rankin conducted an unannounced Case Management - Deficiencies inspection due to deficiencies observed during the investigation for Complaint control # 29-AS-20250604185454. LPA met with Back-up Administrator Claire Aviado and explained the reason for the visit.

During the complaint investigation LPA did a review of medication records for residents currently residing at the facility, the following deficiency was observed:

An audit of the Centrally Stored Medication and Destruction Records (CSMDR) and Medication Administration Records (MAR) LPA noted 11 medications refills were not logged as required. It was observed that there was three months’ extra supply of medications on hand that had not been recorded. Additionally, an audit of the medications showed missing CSMDR logs for January medications. Further review showed that the medication refills were not used in order of the supply on hand, the records stated that refills used in August were July refill and September was August refill, but LPA found that the July and August refills were still pending use and the records were inaccurately recorded. In one case the prescription stated one tablet by mouth twice a day, but facility had reduced the medication to one time a day due to the medication side effect on the resident but had not obtained a discontinue or updated doctor’s order to support the change.