Facility Evaluation Report

On 6/4/26, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Wendy Counta.

The regional office received self reported incident reports regarding medication administration errors:

· On 5/11/26, R1 was administered 10 mg of Propanolol rather than the 5 mg ordered. The dose increase from 5 mg to 10 mg for this medication began the following day, 5/12/26.

· On 5/19/26, R2 had a medical appointment due to back pain. R2 was prescribed a pain medication and a muscle relaxant. Medications were picked up at the pharmacy and upon return to the facility, R2 was given both as needed medications before reviewing the medication orders. The order, when received and reviewed stated that pain meds are to be used until completed and begin the muscle relaxant as needed. Both medications were not to be administered together.