Facility Evaluation Report

Licensing Program Analyst (LPA) Hiratsuka, conducted this unannounced plan of correction visit. This is a follow-up to a deficiency cited on 04/01/2026, when LPA was conducted an unannounced prelicensing visit because this facility is undergoing a change of ownership.

During the visit on 04/01/2026, LPA learned a resident did not receive a medication for almost a month because the medication was ordered on the day of the last dose, it arrived at the facility about fifteen days later, but was put with the overstock medications instead of being logged in correctly and the missed medication was brought up by the resident on 04/01/2026. The medication was restarted on 04/02/2026.

LPA received a written plan of correction via email later on 04/01/2026, stating the staff will be retrained on 04/07/2026, and the medication program system will be checked weekly by a member of the facility administration team. LPA also received a copy of what the staff were trained on and a signed staff attendance sheet on 04/07/2026.