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32 | LPA noted that the AM shift for that months shows a total of 6 staff call offs of which 3 of 6 were covered with additional staffing and of the 3 that were not covered with additional staffing, there were a total of 3 medtechs, 4 caregivers, and one administrator working. LPA noted that on the PM shift for April 2026, were 6 staff call offs. 4 of 6 call offs were covered with additional staffing, the other 2 of 6 shifts there were 2 medtechs and 5 caregivers working those pm shifts. LPA noted that overnight (NOC) shifts staff call offs. 2 of 2 additional staffing were noted to cover those call offs. At this time there is not sufficient evidence to support the allegation of, “Facility is not sufficiently staffed to meet the needs of residents in care.” and is unsubstantiated at this time.
As to the allegation of, “Staff do not ensure medication is stored in originally received containers.” and “Staff do not have the required training.” It was alleged that, “staff do not ensure medication is stored in originally received container and staff do not have the required training.” It was discovered through inspection, observations, and interviews that on 04/22/2026 LPA Jeffries conducted a cursory medication audit and noted not “pre-pulled” medications during this medication audit and no medication stored improperly. On 06/15/2026 LPA observed medication cart and noted that medications that were prepared were for the current am medication pass on 06/15/2026. LPA noted that medications were properly stored and not pre-popped during both random medication audits and observations. On 04/22/2026 LPA conducted an in-person interview with medtech (S1). S1 stated that medications are never pulled until prior to medication pass, “at the most one-hour prep before that med pass.” S1 said that they have 4 years of experience as a medtech and the facility has mandatory annual medtech training. On 06/15/2026 LPA conducted in-person interviews with S2, and S3, both staff have current medtech training from facility, both S2 and S3 stated they only pull medications for the med pass they are doing next and never prepull medication. On 04/22/2026, LPA conducted an in-person interview with Administrator, Meshell Ramos, who stated that all medtechs have up to date training and additional medtech training is provided to direct care staff. LPA reviewed training documentation for the annual Medication Administration (medtech) Training and noted that 8 of 8 staff who are scheduled as medtechs have medication administration training within the last 12 months. At this time there is not enough evidence to support the allegation of, “Staff do not ensure medication is stored in originally received containers.” And is unsubstantiated at this time.
CONTINUED on LIC9099-C |