Facility Evaluation Report

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced Plan of Correction (POC) inspection for the purpose of following up on deficiencies cited during required annual inspection. LPA was greeted and granted entry by Staff Arlyne Cornejo and purpose of the visit was discussed.

Deficiency 87465(a)(5)(A) was cited due to there being no authorization from Resident’s 1 (R1’s) physician for one of their prescribed medications. During today’s visit, LPA observed there is still no authorization from R1’s physician for one their prescribed medications. Per Staff, medication has been discontinued however was unable to provide a discontinued order from R1’s physician and the medication remains with R1’s centrally stored medication.

Deficiency 87465(h)(2) was cited due to medication requiring refrigeration being observed to be accessible to all facility residents in the kitchen fridge. During today’s visit, LPA observed there is a separate mini fridge with a lock in which medication requiring refrigeration is centrally stored.

Deficiency 87303(e)(2) was cited due to water temperature testing between 138.3- and 152.6-degrees Fahrenheit. During today’s visit, water temperature tested at 131.0 degrees Fahrenheit.

Deficiency 1569.625(b)(2) was cited due to staff files not containing 20 hours of annual training conducted. During today’s visit, LPA conducted file review for two of two staff files and observed files did not contain 20 hours of annual training. Per Staff, they have not completed required annual staff training.

Deficiency 87465(h)(5) was cited due to medication for residents being pre-poured into a plastic weekly medication organizer three days in advance. During today’s visit, LPA observed medication for residents is no longer being pre-poured. (Cont. LIC809-C)