Facility Evaluation Report

On 10/16/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to conduct a case management. LPA Campbell met with Zenaida Tabhan, Administrator and explained the purpose of the visit and consultation.

LPA Campbell reviewed the incident report and interviewed the Zenaida regarding a medication error that occurred on 10/02/2025. Per the Unusual Incident Report (UIR), weekly medication (Alendronate/Fosamax) was given in error on the incorrect day of the week. Normally, the medication was given on Thursday but was instead given on Sunday, less than a week apart. Per Zenaida, this was due to an administrative error when the monthly MAR was created and there was a lack of additional verification by the licensee and/or administrator. LPA Campbell reviewed the Medication Administration Record (MAR), Medication Reason for Use (MRU) and Current Medication List (CML) and found that staff had changed the day of the week to Sunday for the medication when August ended.

To address the medication error, the facility conducted an in-service training for med pass, that included: a 7 rights video, a question and answer session after the video for discussion with staff and practiced med passes via role playing.