Facility Evaluation Report

On 3/16/26, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to conduct a case management visit. LPA met with staff and explained the purpose of the visit. Regional Director of Operations, Vanessa Potier Watts came after short while and assisted LPA with today's visit.

R1’s and R2’s AWOL Incidents- The facility submitted a completed Unusual Incident/Injury Report (LIC624) regarding resident (R1) left facility unattended on 2/14/26 at approximately 1:55PM. Per incident report, R1 was seen by staff around 1PM that day and R1 left facility by a side door without any staff noticing. The facility submitted a completed Unusual Incident/Injury Report (LIC624) regarding resident (R1) left facility unattended on 2/26/26 at approximately 11:20PM. Per incident report, R2 told the staff that they do not want to reside there and left facility at their will. Facility notified R1 and R2’s physician, responsible party, law enforcement and other required agencies regarding this AWOL incident. R1s and R2’s medical assessment, LIC602 indicated they were able to leave the facility unassisted.

R3’S Incident for medication error - The facility submitted a completed Unusual Incident/Injury Report (LIC624) regarding resident (R3) on 02/13/26 which indicated that R3 was given a double dose of medication Lamictal (300mg of 150 mg - 8 times was administered instead of 4 times). Staff indicated they did not notice that the facility had a duplicate prescription of this medication on file for R3 which resulted R3 was given double dose of this medication in error. The resident did not sustain any adverse effects from the medication error. Facility notified R3’s responsible party, physician and other required agencies regarding this medication error. Based on gathered information, citation has been issued per Title 22 Regulations as indicated on LIC-809D.

Furthermore, record review and staff interviews indicate that facility administration notified assigned LPA regarding these incidents (for R1,R3) via email around 2/17/26 but completed incidents reports were not sent to department till 2/26/26 after LPA requested the reports. Even though both incidents’ reports (LIC624) for R1, R3 were generated around 2/17/26, it was not sent to department till 2/26/26 as required per Reporting Requirements per Title 22 Regulations. therefore, Technical Advisory has been issued.Civil penalties may be assessed if facility does not comply with POC requirements which were issued today. Exit interview was conducted ,appeal rights and copy of the report was provided.