Facility Evaluation Report

On 04/26/2023 at 8:11 AM Licensing Program Analyst (LPA) David España conducted an unannounced annual continuation visit to the facility. The purpose of today’s visit was to conduct a required 1 year annual inspection. LPA met with Administrator Gabriela Chavez and explained the reason for today's visit.

At 8:20 AM LPA España and staff went to the Medication Room located on the 1st floor of the facility and met with Med Tech staff regarding the medication procedures. LPA España and staff stated Med Room is kept locked and is not accessible to residents. LPA España observed that medications are centrally stored in the Medication Room and observed and reviewed four residents MARs. LPA España interviewed staff and specified residents’ medications are prepared one hour prior to dispensing the medications and are color coded green (e.g., morning) and blue (evening).

LPA España interviewed staff, and stated each resident has a MARs for the Month which list all residents’ medications per physician orders. LPA España interviewed staff which has stated that they (staff) do an assessment of the MARs for the date, time, medication, dosage and frequency. LPA España interviewed, observed, the protocol in place for all of the residents’ medications from the original container into a clear plastic cup with the resident’s name on it and places a clear lid on the clear plastic cup. LPA España interviewed, observed, the protocol of the clear plastic cup which are then placed into a tray that has a location for each individual resident’s medication cups with the names of the resident visible to the staff. LPA España interviewed, observed, the protocol of all medication cups is prepared and placed in the tray, the tray is placed in plastic container in order to transport the medications to the residents without spilling, mixing or contaminating the medications. LPA España interviewed, observed, the protocol which provides the resident their medications, prior to giving the medications, the staff is trained to pick up the Medication Cup and verify the medication is for the correct residents before administering it. At 9:36 AM LPA España and staff observed that the staff removes the lid off the clear plastic cup and places the residents’ medications into a clean cup and gives the medication to the resident to take with a cup of water. The staff verifies the resident took their medications and places the empty clear plastic cup back into the tray and moves on to the next resident.

staff indicated that residents’ medications are prepared.