Facility Evaluation Report

At 3:15 pm on this day, November 5, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual inspection that was started on October 30, 2024 and met with Aura Rubilyn 'Ruby' Bucu, staff. LPA called and spoke over the phone with Adora Santiago, administrator (ADM), and informed the reason for visit.

LPA reviewed 5 residents' records. Medications were inspected and compared with doctor's orders and LIC622 Centrally Stored Medication Records.

-at 3:40 pm, R1's LIC602 showed R1 ambulatory, not consistent with R1's non-ambulatory status. R1 uses cane and walker for mobility.

-at 3:55 pm, resident's (R2) LIC602A Physician's Report was signed by social worker (LCSW).

-at 4:10 pm, resident (R5) has no LIC9172 Functional Capability Assessment on file.

-at 4:35 pm, R1 lists/order of medications on file do not have the frequency of administration. Medications filled on 10/2024 do not have LIC622 Centrally Stored Medication and Destruction Record.

-at 4:50 pm, resident(R2) has doctor's order/recent medication list on file dated 8/2024 but facility does not have the following medications: clotrimazole; lidocane cream; Aquaphor; trihexyphenidyl. Carbamazepine and Haloperidol are 100 mg and 5 mg but the medications in the facility are 200 mg and 10 mg respectively. Medications filled on 10/2024 have no LIC622.

-at 5:05 pm, there's no doctor's order for R3's 10 medications. Medications filled on 10/2024 have no LIC622.