Routine inspection (multi-day)·January 9, 2024

LPA made subsequent visit to complete annual inspection. LPA Met with Monica Aguilera who assisted with the visit . THE (CARE) tool was not functioning for this annual inspection and LPA observed the following: Client Records/Incident Reports: Six (6) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records. Health Related Services: Clients are assisted with self-administration of prescription medications. Six (6) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked cabinet and not accessible to clients in care. Medications are given according to Physician orders. Incident Medical and Dental: LPA reviewed all 6 Resident's medication files and observed that R5 did not have refills for one medication and last item they took that medication was on 01/05/2024. Deficiency cited, exit interview conducted and copy of report and appeal rights provided.