Facility Evaluation Report

On 5/22/25, Licensing Program Analyst (LPA), Kevin Mknelly, and Licensing Program Manager, Maribeth Senty were present for a Non-compliance Conference via Microsoft Teams today with Zachary Butcher, Nathan Condie, and others who the licensee invited to attend.

This meeting was called to review the status of facility's compliance plan that was established on 2/6/25.

Topics discussed during this meeting were:

Continued incidents of non-compliance related to some of the topics addressed in the compliance conference of 2/6/25.

Ways in which the existing compliance plan will be enhanced to address the medication errors identified on 3/14/25 and 3/26/25 and well as issues identified in monthly audits such as communication with physicians, medication records and medication refills

In today's meeting, the licensee agreed to submit an amended quality assurance policies and procedures that have been added or developed as a result of ongoing issues noted.

A follow-up conference is to be scheduled, as needed, based on compliance performance.

A copy of this report will be provided to the facility via email. A copy will be signed and returned to CCLD.