Non-compliance follow-up·February 21, 2025

Unannounced case management visit made out to this facility on 02/21/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Andrea Armstrong, at this time. A brief interview was conducted with the facility designated Administrator at this time. Current census was 92 residents, of which 29, resided in the memory care unit also referred to as Traditions. The purpose of this case management visit was to conduct a quarterly visit as outlined from the Non Compliance Conference held on 03/25/2024 and the requirement to have increased monitoring at that time. The focus of this quarterly visit was to review the following items that were initially brought forth on 03/25/2024: Medication Errors Staffing Concerns Reporting Requirements Medication Training Facility Polices Regarding: Assessments, Monitoring of Residents, Change in Condition, Medication Errors A tour of the memory care unit, Traditions, was conducted. A review of the living areas, dining area, and all other areas intended for resident use was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. A tour of the memory care unit medication room was conducted. This LPA was met by the current medication technician, Lakena Touch, who was interviewed at this time. Policies and procedures involving the handling, dispensing, and documentation of the resident medications were discussed with the present medication technician at this time. A review of the facility Medication Administration Record was conducted. It was observed that this facility currently employed an electronic Medication Administration Record (E-MAR) system as well as documenting on forms and documents as well. A review of the facility narcotics policies and procedures was conducted. In addition, a review of the Controlled Medication Administration Record for the resident narcotics was conducted. A review of (10) facility resident files was conducted at this time and noted on the following LIC 858. The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. A civil penalty was assessed in the amount of $250 for a repeat violation on the following LIC 421 FC. Appeal Rights were printed and a copy was given to the facility designated Administrator Andrea Armstrong at this time. Exit Interview