Facility Evaluation Report

Licensing Program Analyst (LPA) Sarah Hurt conducted a Case Management visit. LPA met with facility Facility Administrator, Jose Vitan and explained the purpose of today's visit.

LPA Hurt is following up on an incident from 04/20/2024 involving Resident 1 causing them to be hospitalized. LPA Hurt reviewed Resident 1's Physicians Report, Centrally Stored Medication Log, and Medication Administration Records. Resident 1's Physician Report documents they need assistance with Administering Medications.

Resident 1 was in the hospital beginning 04/20/2024 Administrator stated Resident 1's medications that weren't taken when hospital was hospitalized were given to the pharmacy, and was not documented on Centrally Stored Medication log. LPA Hurt was unable to count the medications for Resident 1 as they were given to the pharmacy. Facility staff was not correctly documenting Centrally Stored Medications for Resident 1. Resident 1's Centrally Stored Medication log also documents medication # 406389 to be given at noon, and bedtime. Facility staff signed for Resident 1's medication #406389 at 9 p.m., but consistently did not sign for the noon medication.

The following deficiencies are being cited Per Title 22 Regulations.

Exit interview conducted with facility Administrator, Jose Vitan, and a copy of this report provided.