Facility Evaluation Report

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Annual Continuation . LPA was greeted and allowed entry into the facility and conducted the visit with Licensee, Maria "Erolyn" Delgado.

During today's annual continuation, a brief tour of the facility was conducted along with records, and medication review. The facility has routine and over the counter medications without physician's orders. There were multiple bottles of medications that were expired. Also observed were loose pills within the basket/container that stored the medications. Some over the counter medications did not have a label or name to identify who the medication belonged to. Medications were stored on top of food items. Medications are being disposed of in the trash. Medications are not being logged on a Centrally Stored Medication Destruction Record.

The facility was not in good repair. The living room sliding door screen is torn. The main bathroom for resident use has a flickering light and the shower needs to be cleaned of the debris/mold. Resident beds did not contain required bedding to include mattress pad, fitted sheet, and top sheet. First aid kit was incomplete and missing bandages, dressing, antiseptic solution, and current first aid manual. The facility is not conducting disaster drills. The licensee has not conducted annual training on the Emergency and Disaster Plan. Staff and resident records did not contain required documentation or training.

Based on today's inspection, deficiencies were observed and cited on the attached LIC 809D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Licensee, Maria Delgado whose signature below confirms receipt of these rights.