Facility Evaluation Report

At 9:20am, on 7/7/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct a Case Management – Incident visit. LPA met with Administrator Adam Bramwell, announced who he was and the reason for the visit.

On 2/27/2026 at 11:43 p.m., the Administrator emailed the LPA to report that, during an audit conducted earlier that day by Omnicare pharmacy staff, multiple bottles of liquid narcotic medications were found to be missing. The Administrator stated that a full investigation was underway with the involvement of local law enforcement.

On 3/2/2026 at 10:20 a.m., the LPA spoke by phone with the Administrator and the previous Health and Wellness Director about their internal investigation. They reported that eight (8) bottles of liquid narcotic medication were missing from the locked medication refrigerator in the medication room located on the first-floor. These medication bottles are kept inside their original packaging box with the pharmacy label. According to their investigation, a hospice nurse managed medications for two of the residents with missing medications and confirmed they observed the two medication bottles they managed were present on 2/26/2026 at around 11:00 a.m. Later that same day, at about 7:00 p.m., Staff #2 (S2) checked all eight medications for refill needs and confirmed that all eight bottles were present in their labeled boxes. On 2/27/2026 at about 11:00 a.m., Omnicare pharmacy staff discovered that the eight bottles were missing during a scheduled audit. The boxes with pharmacy labels were still in the refrigerator, but the medication bottles were not inside. At approximately 4:00 p.m. that day, the Administrator contacted local law enforcement.