Facility Evaluation Report

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an subsequent annual continuation visit. LPA met with Executive Director Myla Belson and informed her the reason of the visit.

On 10/02/2025, during the annual audit inspection conducted from 9:30 a.m. to 3:30 p.m., (LPA) continued the audit review of resident records, specifically auditing centrally stored medication records and conducting a physical count of medications. LPA reviewed medication and records for 14 residents out of 101.

The audit revealed discrepancies for 6 residents. Specifically, the initial dates of medication administration did not align with the actual medication counts, resulting in off-count errors. In addition, LPA observed leftover medications from prior monthly cycles, as well as multiple months of overstocked medications that had not been destroyed or returned to the pharmacy as required.

These findings demonstrate a improper medication management, including inaccurate record keeping and failure to dispose of or return unused medications, which poses potential health and safety risks to residents.

Citation issued//appeal rights, exit interview and copy of report provided.