Follow-up on corrections·July 24, 2024

On 7/24/24 Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived at the facility unannounced to conduct a Case Management visit. LPA met with Executive Director (ED) Ricky David and explained the purpose of the visit. On 03/28/24 LPAs conducted a medication audit during a complaint investigation. During the investigation, the following deficiencies were found: LPAs observed that R1 medication Amlodipine Besylate 5 MG had a start date of 03/09/24 had two (2) extra tablets than what was documented as dispensed. The MAR indicated that R1 had not missed or refused the medication. R1s medication for Metoprolol Succinate 25 MG with a start date of 03/14/24 had one (1) extra tablet than what was documented as dispensed. The MAR indicated that R1 had not missed or refused the medication. Medication audit revealed several staff are pre-pouring resident's medications for up to 24 hours. Additionally, it was learned staff are keeping their pre-poured medications locked in a cabinet that only that specific staff has access to. Violations were observed during the Department medication audit therefore citations will be issued and listed on the LIC809-D. Exit interview and appeal rights provided.