Follow-up on corrections·August 2, 2024

Licensing Program Analyst (LPA) Angela Panushkina conducted unannounced Case Management visit to this facility in conjunction with a complaint control #31-AS-20240606085307. LPA met with the Administrator and explained the reason for the visit. The purpose of this Case Management visit is to address the deficiencies that were observed during the initial complaint investigation conducted on 06/14/24 not related to the complaint. During the file review and Centrally Stored Medication and Destruction Records (CSMDR), LPA observed the following: R1 was admitted to this facility on 05/31/24 with Pro re nata (PRN) and prescribed medications (bubble pack) from the Pharmacy #1. As of 06/04/24 R1 was admitted on Hospice and a new PRN and prescribed medications (bubble pack) were delivered from Pharmacy #2. During the CSMDR record review, LPA observed all medications from Pharmacy #2 were registered/listed. However, two (2) PRN medications from Pharmacy #1 were not registered. Moreover, LPA observed the refill date for those two (2) PRN medications was on 06/05/24, but the PRN log indicated that R1 took/started the pills on 06/03/24 and 06/04/24. LPA conducted an interview with the Administrator who confirmed that R1’s previously ordered PRN medications were not registered in CSMDR, since there were less than five (5) pills left. Deficiency issued per Title 22. Exit interview conducted appeal rights explained and copy of this report signed and delivered.