Facility Evaluation Report

On April 23, 2025, at 9:00 AM, 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 the resident (R1) was administered the incorrect medicine by a staff member. Upon arrival, LPA met with the Chief Operating Officer (COO) Elvyra Abare and Assistant Administrator (AAD), Beth Shirley. The LPA disclosed the purpose of the visit.

LPA interviewed three (3) staff members: S1, S2, and COO.

LPA interviewed S1 over the phone. S1 stated that on 04/17/2025, they had received a call from staff (S2) reporting a medication error. S2 had administered one of the Assisted Living (AL) resident’s morning medications to Independent Living (IL) resident R1. According to S1, S2 was conducting a medication pass when the phone rang. S2 grabbed a medication cup from the top of the med cart and administered the medications to R1. IL residents who are on medication management typically go down to AL to receive their medications. After completing the phone call, S2 realized that R1’s actual medications were still on the cart, but R1 had already left. R1, R1’s family member, and R1’s primary care physician (PCP) were informed about the medication error. R1 was offered the option to return to AL for monitoring. The PCP recommended that staff monitor R1 and continue with their regular medications.

The COO stated that the nurse responsible for the medication error would receive education and training. The plan was to assign the nurse a Relias training module, including a reminder on medication administration protocols and a quiz.