Facility Evaluation Report

Licensing Program Analyst(s)(LPA) Mary Flores conducted a case management visit during a complaint investigation visit conducted on 8/29/22. LPA Flores met with Lydia Pabion Administrator and explained the reason for the visit.

On 8/29/22 LPA Flores reviewed medication sheets for Resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6) during the review LPA Flores observed medication sheets were not updated for morning dose provided to each resident. Per facility's nurse (LVN) medication is provide to residents either during breakfast at the dining room, or residents walk to the medication room to request, or provided in the residents room and does not note after providing the dose to each resident at the time each is provided. LPA Flores observed medication bubble packs are out of cycle and was unable to identify if medication was provided that morning. LPA Flores observed medication bubble pack for Resident #7 was crossed out with black marker and rename with red marker with R2's name. Per administrator pharmacy made a mistake in the order and place the order for R7 instead of R2. LPA Flores observed R2 and R7 had two sets of bubble packs for the same medication for each dose. Last medication training provided on 8/21/22,

Deficiencies were given based on observations per Title 22 Division 6 Chapter 8 and noted on LIC809D.

Exit interview was conducted with Lydia Pabion - Administrator and a copy of this report, LIC 809D, and appeal rights were provided.