Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings on complaint #21-AS-20260416130250. During investigation, it was revealed that resident (R1) has a doctor's directive to have blood sugar checked every morning. LPA reviewed physician's report for R1. Current medication orders include a glucose monitor, lancets, and test strips. LPA discussed with licensee the current doctor's orders for glucose monitoring. Licensee advised that R1 does not have any current orders for diabetic medication as they do not have diabetes. Licensee was not aware of any glucose monitoring supplies prescribed to R1 by their doctor. Additionally, licensee advised LPA that facility does not have a pharmacy and therefore verbally advises resident's responsible parties, upon admission, that the facility will not be responsible for filling medication orders. Facility will always help residents with self-administration of medication, but does not fill or refill prescriptions.

Facility staff interviewed report never having been asked to monitor blood sugar for R1 nor have they ever received any glucose monitoring supplies with which to test. Licensee will ask for clarification from R1's doctor and responsible party as to the doctor's orders for glucose monitoring and if required facility will implement helping R1 with testing according to doctor's orders.

LPA discussed with licensee ensuring documentation is present for all residents and responsible parties outlining facility medication ordering procedures and policies.

No deficiencies cited during this visit. Exit interview conducted with caregiver and a copy of this report given.