Facility Evaluation Report

On July 1, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit in relation to an incident that occurred on 6/22/25. LPA met with Health and Wellness Director, Carmen Bodnar and explained the purpose of the visit.

On 6/22/25, the Licensee reported that registry LVN/Med-tech administered an incorrect dose of Lacosamide medication to Resident 1 (R1) during the AM shift. R1 was supposed to receive 100mg of Lacosamide, however 150mg of Lacosamide was given.

During the visit, LPA reviewed R1's file, including but not limited to; physician's orders for medication, medication list, medication administration record (MAR), and R1's medication bottles.

Based on R1's medication list, R1 is required to take 1 tablet of Lacosomide (100mg) medication daily at 8am, however the med-tech administered 150mg. The facility failed to provide R1's medication as prescribed by the physician.

According to the Health and Wellness Director, registry med-techs are always trained prior to administering medications for residents. In addition, it was reported that during each shift, med-techs are required to count all residents' medications.

On 6/26/25, the Licensee reported that registry med-tech, provided R1 one tablet (100mg) of Gabapentin at night at 8pm, however Resident 2 (R2) noticed and reported that R1 is supposed to receive three tablets of Gabapentin instead. The med-tech then provided R1 with two more tablets.