At 11:30am observed Assisted Living (AL) Medications Room. Upon LPA's entry to the Medications Room though an open unlocked door, observed medications cart unlocked while Staff one (S1) was on the phone back turned away from medications cart sitting at the desk. LPA immediately locked the medications cart, S1 hung up the phone and stated they did not have the key, they left it at home, ADM provided a back up key from the office. Hot water in medications room within regulatory range of 105*F to 120* F at 111.6*F. Two open and partially used applesauces stored the medications refrigerator, ADM immediately disposed of them. An expired flex pen dated 10/19/2020, ADM immediately removed and instructed S1 to dispose of it. Multiple resident's medications were stored together in a container labeled for a resident no longer at the facility, ADM instructed S1 to organized the medication's refrigerator. Resident One (R1's) diabetes kit not observed in Medication's Room, Staff two (S2) stated R1 checks themselves, during record review noted on R1's LIC 602, R1 is not able to preform own glucose testing. ADM instructed S1 and S2 to review all diabetic resident's medications and care plans. Resident two (R2's) methadone was discontinued by doctor's order on 2/18/2021 and observed locked and stored in the medications cart. Resident three (R3's) antibiotic was labeled for one pill every eight hours for seven days. R3's Medication Administration Record (MAR) documented medication was administered twice daily from 2/18/2021 to 3/2/2021 and no doctor's orders were found for the order of antibiotics. Resident four (R4's) morphine on hand quantity of 29 syringes, one dose given documented by S2 signature but S2 stated they gave it to the Hospice nurse to push but the Hospice nurse did not sign off administration. 12 of 29 morphine syringes were not labeled, stored in a bundle.

Observed 5 resident rooms on first floor AL. Rooms observed with all necessary furniture and lighting. Restrooms observed with non slip shower floors and grab bars. Resident rooms had paper towels sitting on the counter not in a dispenser. At 12:20pm observed yellow zone room 101 with all necessary signage posted with trash can covered but not touchless.

At 12:41pm observed MC unit medications room with medications not labeled. Staff four (S4) stated the pharmacy would not cover the medications so the family had purchased it. LPA provided guidance to only purchase through the pharmacy as so it was all labeled. Observed one medications count of narcotics, properly labeled and 20 of 20 morphine syringes counted.

The following are required before facility can be approved for licensure:

1. Complete Roof Repair Work