Facility Evaluation Report

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Health Checks visit to check on the health and safety of residents in care. LPA was greeted and allowed entry into the facility and met with Licensee, Maria Erolyn Delgado.

During today's visit, LPA briefly toured the facility, observed and interviewed resident's in care, interviewed staff, review of medications, records, sufficient food supply, and physical plant.

On 03/26/25, LPA observed staff cleaning a skin tear/wound on Resident #1's hand. Staff were cleaning the wound with wound cleanser, applying anti itch lotion, and a bandage. The facility did not have the current hospice records but indicated the nurse was on their way to the facility to provide current documentation. Today, 03/28/25, a review of hospice records indicated instructions on how to clean the wound, which was not followed by the facility staff. Today, the hot water temperature for resident use measured at 135 degrees F. The licensee stated she turned the hot water temperature to hot because the water wasn't getting hot enough. The licensee posted a warning sign of the hot water temperature above the sink faucet warning users. A review of medications indicated Resident #2 and Resident #3's medications are not being given as prescribed. The facility does not use a Medication Administration Record. The facility's Centrally Stored Medication Destruction Records were not current. The licensee was unable to explain the medication errors. The bubble packs showed the prescription was issued the end of February 2025. However, the bubble pack was not punched in date order and should reflect thru today's date as medications given. The bubble packs for the end of February 2025 were only punched for up to 4 days, showing medications were not given accordingly in March 2025.

Deficiencies were observed and issued on the attached LIC 809D, along with civil penalties for repeat violations. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Licensee, Maria Erolyn Delgado whose signature below confirms receipt of these rights.