Facility Evaluation Report

On 5/23/2025, Licensing Program Analysts (LPA) Rachel Bruce and Daiquiri Boyd conducted an unannounced case management visit and met with Elizabeth Reynaga, Administrator (AD). The purpose of the visit was to discuss a recent incident report submitted on May 19, 2025 from the above facility.

The incident report was regarding a medication error and described that on May 16, 2025 a staff Medication Tech (MT) gave the wrong medication to a resident (R1). MT self reported the error to her supervisor and immediately R1's doctor was notified. R1 was monitored by staff and at approximately 11:30 am it was decided to send R1 to the hospital for lab work and to ensure there were no ell effects from the medication that had been given to her in error. Ultimately it was determined that there were no signs of any side effects and R1 was released to return to the facility.

LPA and AD discussed the incident and the seriousness of the mistake. At today's visit the facility will be receiving a citation for the error. See attached confidential names list and deficiency page.