Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. LPA met with Administrator (ADM) Aida Urena.

The purpose of the visit is to follow-up on an incident report received on 08/13/2025 regarding missed medications for resident (R1) that occurred on 08/11/2025. It was reported that on 08/11/2025 at 5:30pm, 2 of R1’s routine medications were not administered as prescribed.

Based on interview with the Administrator (ADM), it was stated that at the time, staff (S1) was assigned as a charge staff to assist with medications. The medication error was discovered during the NOC shift medication count wherein the ADM was informed about an over count of medications. ADM states to have counted the medications the next day (08/12/2025) to confirm the medication error. ADM states that upon following up with S1, S1 stated that the shift was "chaotic" and thought to have assisted R1 with his/her 5:30pm medication. ADM confirmed the medication was not given based on the medication counts conducted daily during NOC shift.

ADM stated R1 was the only resident who missed their 5:30PM and no other residents was affected. It was stated that after it was discovered that R1’s medications were not administered, the Administrator informed R1’s physician, responsible party, and submitted the incident report to the regional center and licensing. It was stated that R1 did not show any signs of discomfort or withdrawals from missing the 2 medications.