Facility Evaluation Report

On 09/11/2025, LPA J. Duarte and S. Doucette arrived at the facility unannounced to conduct a compliant investigation. During the course of the investigation, LPAs observed deficiencies. LPAs met with Administrator (AD) Jessica Pelaya.

LPAs reviewed resident records including: Centrally Stored Medication, MARS, medication in Memory Care for R1 and R2, hospice records, admission agreements, and physician reports.

During the course of the investigation, LPAs observed the Centrally stored medication log for R1 has a start date of 09/01/2025; however, medication bubble pack has a label indicating Date Opened is 09/05/25. Medication bubble pack shows eight pills out of 28 were administered for the evening and the bubble pack for the morning shows seven out of 28 were administered for the morning. In addition, a medication that indicates to be administered at Noon by pharmacy was crossed out and above was hand written "2 PM."

Facility was unable to provide a centrally stored medication log for R1 and R2 for the month of August of 2025. Facility was unable to provide hospice records for review for R2.

During the tour of the facility, LPAs observed latch locks on the outside of the main building, on top of the door, preventing residents from exiting the facility. LPA took photos.

An exit interview was conducted and a copy of this report was provided with plan of correction and appeal rights. Civil penalty was issued for fire clearance.