Facility Evaluation Report

On 07/07/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit. The purpose of this visit is to deliver deficiencies observed during the course of the investigation regarding complaint control number 11-AS-20260122103758. LPA met with the Executive Director, Suzette Johnson, and the purpose of the visit was explained. LPA was granted entry to the facility.

Record review of the facility Plan of Operation revealed the following:

· “Medication Refills…Medication refills will be obtained in a timely manner to ensure residents have all physician ordered medication available. 1. The designated staff member contacts the dispensing pharmacy to obtain a refill at least seven (7) days prior to running out of medication…When the medication is ordered it entered onto the Refill Roster…3. Medications are never allowed to run out.”

· “Missed or Refused Medications…1. Missed/refused medications are documented in the resident’s medication record…”

· “Blood Pressure and/or Pulse Reading to Determine the Need for a Medication…resident’s vital signs are taken to determine the need for admiration of medications: a)…A written record is made on the MAR. b) When the medication is given, the date, time, and initials of the person who took the vital signs and/or gave the medication are documented.

· “Assisting with Administration: Oral Medications…5. Document administration of medication on them Medication Assistance/Administration Record.”