Routine inspection·November 15, 2024

Licensing Program Analyst (LPAs) Dwayne Mason Jr. and Nancy Guillen arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPAs were greeted at the facility by facility staff. LPAs met with Jerry Rodriguez, Administrator and explained the purpose of the inspection. The facility is three-story building with 107 resident rooms. The first floor houses 34 resident rooms as well as a family room, lobby, reception area, administrative office, break room, medication room, laundry rooms and kitchen. The second floor houses 37 resident rooms, maintenance office, beauty shop and break room. The third floor houses 36 resident rooms, break room, activity office, library and temporary office space. All resident rooms had the required elements, including bed, chair, closet space and ample lighting. Facility has toxins, chemicals and cleaning supplies locked in storage closets on the second floor. Restrooms are stocked with soap and paper towels. Hot water measured between 105 and 120 degrees F. LPA observed facility has emergency food and water supply as well as additional emergency supplies. LPAs reviewed six staff files and ten resident files. LPAs conducted interviews with ten residents and three staff. LPAs reviewed medication. Based on medication review. LPAs determined facility staff could not locate two PRN medications prescribed to one resident and one non-PRN medication prescribed to a different resident. LPAs also observed missing signatures on multiple Medication Administration Records. Three deficiencies are being issued. LPAs observed two PRN medications prescribed to one resident that had hand-written labels taped over the printed labels. Facility Staff stated they created the labels when the physician's order changed for the PRN medications. Facility staff called the pharmacy and verified the information written on the label was correct. LPAs advised facility staff of regulations prohibiting handwriting or altering prescription labels. A technical violation was issued. Based on today's inspection, three deficiencies and one technical violation are being issued. An exit interview was conducted and a copy of this report and appeal rights were provided to the facility.