Facility Evaluation Report

On 12/09/25 Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with the Director .

On 11/14/25, R1 received medication dispensed by S1 in which medication was dispensed, per order, from capsules to be added to food.

S1 disposed of used capsules to an open trashcan near the staff office.

R2 accessed the trash and removed a small box. Staff attempted to have R2 return the box to the trash but R2 refused.

Upon arriving home, it was found by R2’s family that the box taken from the facility trash contained a discarded capsule. One of the capsules contained a small amount of medication intended for R1.

Therefore, R1 did not receive a full dose of their prescribed medication and R2 accessed medication which was not safely stored.

The licensee has updated policies, procedures and staff training.

Therefore this plan of correction is cleared by today’s visit.

As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed. Copy of report and appeal rights provided.