Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a case management visit and was greeted by facility caregiver. LPA met with Administrator (Admin) Guadalupe Garcia.

On 6/5/26 CCL received an Incident Report indicating a medication error for resident (R1). Report indicates that on 5/30/26, at approximately 9:00pm Admin was notified that staff (S1) had signed for Nystatin powder that was not administered to R1. Upon facility investigation, it was determined that R1 missed one 5:00pm dose. Facility terminated S1 on 6/8/26 for falsifying documentation.

On 6/16/26 CCL received an Incident Report indicating a medication error for resident (R2). Report indicates that on 6/15/26 Administrator was notified that staff (S2) had administered a dose of Claritin D that is prescribed to be given only once every 24 hours. S2 administered the second dose without verifying the time the previous dose had been administered. R2 was subsequently seen by their physician. Resident was monitored for adverse reactions. No adverse reactions observed. Facility has conducted medication training with staff with an emphasis on reviewing MARs, medication instructions, dosage requirements, and administration procedures. Additionally, Administrator will conduct periodic audits of medication records. S2 will be receiving final written today and a Counseling and Corrective Action (CCA). Admin showed LPA paperwork for corrective action.

On 6/17/26 CCL received an Incident Report indicating a medication error for resident (R3). Report indicates that on 6/16/26 facility Administrator was notified by staff that staff (S3) administered two (2) medications prescribed for hypertension. However, R3's blood pressure was reading was outside the administration parameters specified on doctor's orders. Additionally, S3 did not report their error to the Administrator. Upon learning of the error, Administrator immediately contacted nurse consultant for guidance and requested a