Follow-up on corrections·May 28, 2025

On 5/28/2025 at 1:50 PM Licensing Program Analyst (LPA) Shakaricka Hughes conducted a case management deficiencies on the facility, based on observed deficiencies on a complaint investigation control number: 27-AS-20250313150435. LPA is addressing concerns on this case management for the following deficiencies: Food locked in staff room: On 3/19/2025 LPA Lee visited the facility to conduct a complaint investigation. During this visit it was learned that the 7-day non-perishable food supply was not stored in the kitchen area or accessible to residents in care. LPA Lee observed 7-day supply being stored in the staff’s room. LPA Lee advised the care staff that the refrigerator and pantry cannot be locked, as doing so would violate residents' personal rights. This observation was observed not in compliance with Title 22 regulations, Personal Rights of Residents in All Facilities section 87468.1(a)(2). Residents are to be accorded safe, healthful, and comfortable accommodations, furnishings and equipment. Additionally, Residents should served food of the quality and quantity necessary to meet their nutritional needs. If food is locked away and inaccessible, healthful accommodations are not readily available to residents in care. Continuation 809-C Medication storage and discontinued medication: On 3/19/2025 LPA Lee visited the facility to conduct a complaint investigation. During this visit LPA Lee observed medications for 4 out of 4 residents. Upon review of residents' medication boxes and Medication Administration Records (MAR) log, it was noted that R1 had one medication that was not documented on the MAR log, even though R1 has the medication in R1’s medication box and the medication was being administered to R1. Furthermore, it was observed that R3 had two discontinued medications in their medication box, with discontinuation dates of 01/01/25 and 03/11/25 (per care staff). The doctor's orders for the discontinued medications were not present in the resident’s file, and care staff could not locate the necessary documentation (MAR). The facility is not in compliance with Title 22 Incidental Medical and Dental Care Services 87465(6) in that R1’s medications were not recorded. Additionally, Title 22 Incidental Medical and Dental Care Services 87465(e) R3’s medications were not administered; the medications were discontinued and should’ve been properly destructed and documented as required . An exit interview was conducted with the facility administrator Una Waqalala, and the following documents were provided to the facility LIC 809, LIC 809-C, were provided to the facility.