Facility Evaluation Report

On April 28, 2025, at 1:15 PM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding an incident that occurred on 04/17/2025 when staff (S2) conducted a medication count and discovered that the medication count for Panoprazole 40 mg for resident R1 was off by one (1). Upon arrival, LPA met with the Interim Program Administrator (ADM), Kyle Liddle. The LPA disclosed the purpose of the visit.

LPA interviewed two (2) staff members: ADM and S1, and a Physician’s Assistant (PAS).

ADM stated that S2 conducted the med count at the beginning of their afternoon shift and communicated to them that R1’s med count for one of the medications was off by one (1). ADM called and contacted the physician’s office (PAS) about R1 missing the morning dosage of the Panoprazole 40 mg. ADM talked to PAS and received a verbal authorization from them to administer the missed medication anytime during the day. The medication was given to R1 soon after. R1 didn’t had any side effects. ADM stated a verbal training was conducted with S1 to review MAR and proper forms for initialing and going med by med verification with the fellow DSP.

ADM dialed and connected the phone with Physician Assistant (PAS) for LPA to have a conversation with the PAS. The PAS stated over the phone that they gave verbal authorization to administer the missed medication to R1 anytime during the day. This medication was for the resident’s acid reflux and would not have any serious side effects.

S1 stated a lot of commotion was going that day at the time when they were preparing on administering the medications for the residents in the office room.