Facility Evaluation Report

On 4/16/2026 at 11:00 am, Licensing Program Analyst (LPA) Y. Brown conducted an unannounced case management visit regarding two self reported incidents that were reported to CCLD on 4/7/2026 and 4/10/2026. LPA met with Executive Director Glenda Bertucci and explained the purpose of the visit.

The first incident report stated that on 3/29/2026 around 9:00 am, Staff two (S2) was preparing resident (R1's) medication when S2 observed that the expiration date on the medication bottle indicated that it expired on 3/5/2026. The incident report indicated that R1 was given expired medication of Amlodipine 2.5 mg from 3/5/2026- 3/29/2026. On 3/29/2026, S2 noticed the expired medication and notified S3 to verify the expired medication and S3 re-confirmed that the medication was expired. R1's order is Amlodipine 2.5 mg: take 1 tablet by mouth 2x daily at 9:00 am. Physician and POA were notified of the incident. R1 was not resulted injury or medical problem due to this incident. In-service training was provided to staff on 3/30/2026.

The second incident report stated that on 4/3/2026 around 10:00 am, S1 was reviewing R1's Centrally Stored Medication and Destruction Record and observed that there was a discrepancy with medication dosage of R1's medication of Amlodipine 2.5 mg. S1 observed that R1 was given the Amlodipine 2.5mg but staff only gave R1 1 tablet per day due to the previous physicians order dated on 9/10/2025 that indicated to give R1 Amlodipine 2.5mg 1 tablet by mouth daily. When S1 was reviewing R1's documents S1 realized that the medication dosage was changed to Amlodipine 2.5mg: take 1 tab daily by mouth two times a day on the physicians order dated 12/29/2025 that was received from the Skilled Nursing facility when R1 returned back to the facility.