Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit. LPA met with Administrator, Lucero Rodriguez.

The purpose of the visit is to follow-up on a missed medication for resident (R1) from 01/29/2024 and to follow-up on the facility’s building and grounds.

On 01/31/2024, the Department received an incident report regarding resident (R1)’s missed morning medication on 01/29/2024. Based on interview, R1 had a new medication that arrived on 01/29/2024 and the staff accidentally did not administer one of the medications. The medication error was caught on the morning of 01/30/2024. The facility has two staff members who administers the medication and a verifier who verifies the medication administration. After the incident, 2 out of 2 staff members were provided an updated training on after the incident: making sense of what went wrong to prevent future incidents and medication dispensation. R1’s physician and responsible party was informed. No adverse reaction was noted. LPA obtained the following documents: 2 out of 2 staff member's training records, R1's MAR, R1's medication order, and email correspondence.

On 05/02/2024, the facility had a semi-annual review with DDS. During the review, it was noted that the facility’s dishwasher was out of alignment causing the right side of the dishwasher to stick out approximately 2 inches further than the left side, the cabinet door lock on the kitchen cabinet used to store cleaning agents / chemicals was broken, the toilet paper holder in bathroom #2 was broken, the baseboard under the sink of bathroom #2 was detached from the cabinetry, and the toilet in bathroom #2 was reported to be “leaky”. SEE LIC809-C.