Non-compliance follow-up·June 19, 2025

Unannounced case management visit made out to this facility on 06/19/2025 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 97 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 assisted living medication room was conducted. This LPA was met by the current medication technician on duty 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. It was observed by this LPA that on 05/05/2025, 05/17/2025, and 06/01/2025 that there were more than the required (3) entries for the narcotics count which were performed by the oncoming shift medication technician and the off going shift medication technician. This was observed to be evident on 05/05/2025 which had (4) entries and 05/17/2025 had a total of (5) entries made on the narcotics count log. On 06/01/2025, it was observed by this LPA that there were only (2) entries made for that day for the AM and Evening shifts and the Night shift did not have an entry for either the oncoming or off going medication technicians. A tour of the memory care unit medication room was conducted. This LPA was met by the current medication technician on duty 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 the assigned tasks and duties for caregivers to complete for all three shifts (AM, PM, NOC or referred to as Day, Evening, and Night) was reviewed for proper documentation and notation at this time. It was observed by this LPA that there were a total of (7) days ranging from 04/01/2025 through 06/01/2025 where there were not the required (3) entries for AM, PM, and the NOC shift or referred to as the Day, Evening, and Night shifts from this facility. It was observed that on 04/27, 04/28, 05/05, 05/12, 05/19, and 05/21/2025 there were only (2) narcotics counts made for that day missing one from either the Day, Evening, or Night shifts. It was observed that on 04/26/2025, there were a total of (4) entries made for that day with duplicate entries filled in by the responsible staff persons. In addition, the Staff Assignments by Month by Responsible Party/Resident Name for the month of June 2025 was reviewed by this LPA. It was observed that entries were made into this binder for future dates by the care staff when the assigned duties had not even been completed yet. It was also observed that the caregivers did not properly fill out and initial into this binder when the assigned tasks had been completed for that corresponding day. 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 $1000 for a repeat violation on the following LIC 421 IM. Appeal Rights were printed and a copy was given to the facility designated Administrator Andrea Armstrong at this time. Exit Interview