Correction check·June 8, 2023

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced Plan Of Correction (POC) visit to follow up on the deficiencies issued during the Required - 1 Year inspection conducted on 6/2/23. Upon arriving at the facility, LPA met with Administrator / Jennifer Leon who assisted with the visit. The purpose of this visit was explained. On 6/2/23, the facility was cited for: 87465(a)(4) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. On 6/2/23, LPA observed a discrepancy on the labels listed on two bottles of the same medications and the instructions listed on the Medication Administration Record (MAR) for Carbidopa-Levodopa 25/100mg. Bottle 1 of Carbidopa-Levodopa 25-100 Tab states, take 2 tablets by mouth 5 times daily. Bottle 2 of Carbidopa-Levodopa 25/100mg states, take 2 1/2 tablets by mouth 5 times daily. According to the Medication Administration Record states, staff are administering the medication by administering "3 tabs PO QID" (four times daily). POC: On 6/2/23, LPA received a Physician's order for Carbidopa-Levodopa 25/100mg matching the instructions listed on the MAR "Take 3 tabs 4 times per day". Deficiency is cleared and no further action is needed. 87465(a)(4) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. On 6/2/23, LPA observed an empty bottle of FOCUS CBD 25MG CBD gummies (chew 1 gummy PO QD (take once a day) and a new bottle with a refill was not available at the facility. POC: On 6/2/23, LPA received a Physician's order discontinuing the FOCUS CBD 25MG CBD gummies/ Deficiency is cleared and no further action is needed. 87705(h) Care of Persons with Dementia Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. On 6/2/23, LPA observed the exit gate located on the left side of the property facing the street is not enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. The self closing mechanism/latch on the exit gate located on the right side of the property facing the street, is inoperable and does not self close. During today's visit, LPA observed self closing latches were installed on both exit gates and the exit gates were tested and operational at the time of visit. Deficiency is cleared and no further action is needed. An exit interview was conducted and a copy of this report was provided.