complaint·February 25, 2025

Allegation: Staff do not dispense medication as prescribed by physician It was alleged that R1's eyedrops were not dispensed/given as prescribed. To investigate this allegation, LPAs conducted an interview with the Administrator and requested R1's CSMDR. Review of R1's CSMDR records revealed that the last medication registered on the form (LIC622) was Levothyroxine (date filled on 10/18/24). LPAs also observed that the medication bottle had quantity of 30 pills and the bottle starting date was registered as of 10/25/25. Based on the physician's prescription, the bottle was going to be refilled in November 2024. Moreover, LPAs did not observe any eye drops registered on CSMDR. In addition, LPAs observed two boxes of the same eye drops present in R1's room. During the Interview with the Administrator and S1, LPAs asked to explain how the staff follows the physician's order, when two (2) bottles of the same eyedrops are present, one (1) of which was filled on 09/10/24 and the second eyedrop was filled on 01/10/25. Administrator and S1 were unable to provide any explanation and confirmed that the facility made an error by not always following the physician’s order. Therefore, based on interviews, LPAs record reviews and observation, this allegation is Substantiated. Allegation: Staff do not ensure centrally stored medication is locked Upon arrival, LPAs observed a plastic 32qt clear view storage bin placed on a kitchen table. LPAs also observed the bin had R3's sixteen (16) prescribed medications accessible to residents in care. LPAs conducted an interview with the Administrator and were informed that one (1) of the medication cabinet locks is broken and must be replaced, therefore, the staff kept the storage bin on a kitchen table. At 10:15am, LPAs checked the medication cabinet in the kitchen and confirmed that the lock was broken, and all medications were accessible to residents in care. Moreover, LPAs observed five (5) bottles of vitamins on a kitchen table. Interview with the Administrator revealed that the vitamins belong to the staff/Administrator and LPAs were informed that all vitamins will be locked immediately. Lastly, at 10:29am, LPAs observed Ibuprofen bottle with nine (9) tablets, also prescribed to the Administrator, on the top of a drawer, in the living/dining room area accessible to residents in care. Therefore, based on interviews, LPAs observation and inspection, this allegation is Substantiated. Continue on LIC9099-C Allegation: Staff do not refill resident’s medication prescriptions in a timely manner It was alleged that R1’s eyedrops are not being refilled in a timely manner. To investigate this allegation, LPAs conducted an interview with the Administrator and were informed that the staff contacts R1’s responsible party to refill the eyedrops. Administrator also confirmed that the facility notifies the responsible party regarding the refill, but the medications are not always delivered timely. Moreover, LPAs conducted review of R1's CSMDR records and observed that the last medication registered on the form (LIC622) was Levothyroxine (date filled on 10/18/24). LPAs did not observe any eyedrops registered on CSMDR. In addition, LPAs observed R1’s two boxes of the same eye drops present in R1's room. First eyedrop was filled on 09/10/24 and the second eyedrop was filled on 01/10/25. Each bottle had a quantity of 2.5ML with the instruction to have 1 drop in each eye twice a day. 2.5ML contains approximately fifty (50) drops, and following the physician’s order, each bottle can last only 12.5 days. The last bottle was refilled on 01/10/25 and LPAs observed it to be full. During the interview with the Administrator and S1, LPAs asked to explain the reason why the bottle was still full, when on 01/23/24 the refill was due. Both parties were unable to provide any explanation. Therefore, based on interviews, LPAs record reviews and observation, this allegation is Substantiated. Allegation: Staff do not ensure that facility is free of pests To investigate this allegation, LPAs conducted interviews with five (5) residents and four (4) out of five (5) residents confirmed seeing cockroaches at the facility bathrooms and common areas. Moreover, during the physical walk tour, at approximately 10:20am, LPAs observed a cockroach on the wall, in the living room. LPAs asked the staff to exterminate. In addition, at 10:48am, LPAs observed another cockroach in the kitchen wall and in the dining area. Interview with the Administrator confirmed that the facility has pests and LPAs were informed that pest control will be hired. Therefore, based on interviews and LPAs observation, this allegation is Substantiated. Continue on LIC9099-C Allegation: Staff do not ensure that residents are provided with activities To investigate this allegation, LPAs conducted interviews with five (5) residents and all residents interviewed informed LPAs that the facility has no activities during the day. LPAs were also informed that residents watch TV all day long. During the visit conducted on 01/29/25 from 10:00am to 4:30pm, LPAs observed four (4) residents sitting in the living room and watching TV, and one resident was in their bedroom, sitting on the bed. LPAs conducted an interview with the Administrator who confirmed that the facility has no daily activity scheduled for the residents. Therefore, based on interviews and LPAs observation, this allegation is Substantiated. Deficiencies issued per Title 22. Exit interview conducted appeal rights explained and copy of this report provided to the Executive Director.