Facility Evaluation Report

Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to open a complaint, but discovered an unrelated deficiency during the course of the investigation. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit.

This investigation consisted of record review and interviews. LPA Moleski interviewed Revera and two staff members (S1-S2).

In an interview, the facility's medication manager (S1) admitted that there had been a medication error for a resident (R1). S1 said that R1 had not been receiving a medication used to treat Parkinson's disease for several days due to an error in transcribing the prescription order into the facility's medication administration records (MARs). S1 said that R1 missed four daily doses of the medication between September 18 and September 25.

LPA Moleski reviewed R1's MARs. LPA Moleski observed that R1 had been taking the medications four times daily between September 13 and 17. R1 received one dose on the morning of September 18, at which point the medication was marked discontinued in R1's MARs. The medication was started again at 3 p.m. on September 25, and R1 continued to receive their medications as prescribed for the rest of the month.