Facility Evaluation Report

On 11/5/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Administrator (Admin) .

The department received a incident report on 11/3/25 of a medication errors for R1 on 10/18/25.

The time between 10/18/25-11/3/25 for reporting was due to the facility confirming the error before reporting. Reporting requirements were met. LPA and Admin. discussed ways to alert LPA of suspected but not yet confirmed incident.

LPA discussed the incidents with the Administrator who had conducted the internal investigation. The medication that was dispensed in error had a titration schedule that was further complicated by R1 episodes of refusals. The errors by S1 and S2 were found by an evening medication audit/ count.

Medication errors have been a repeat violation at this facility. As LPA is issuing a citation already today as part of completed complaint investigation number 59-AS-20250911093306 , an additional citation is not issued here. Plan of correction for the other incident will address issues involved in the 10/18/25 medication errors.

As a result of today’s inspection, no deficiencies were noted.

Report reviewed. Copy of report and appeal rights provided