Facility Evaluation Report

On March 27, 2025, at 8:55 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 03/19/2025 when the resident (R1) was given a PRN as needed medication by mistake. Upon arrival, the LPA was greeted by the Health and Wellness Director (HWD), Patricia Oliver and Business Office Director (BOD), Diana Smith. The LPA disclosed the purpose of the visit.

LPA interviewed one (1) resident (R1) and four (4) staff members: Executive Director (ED), Health and Wellness Director (HWD), Medication Technician (S1) and LVN Community Nurse (S2).

HWD stated that on 03/19/2025, R1 was given ‘Labetalol,’ a medication that was ordered as needed. R1 knew their medications well and told the Med Tech that they were not supposed to have the medication unless there was a specific need for it and R1 said they should not have received this medication. HWD stated that S1 did not read or recognize the medication order on the QMAR as an as-needed order, and R1 was concerned about having received the wrong medication. HWD stated that R1 had been diagnosed with Parkinson’s and was receiving care in the elite care unit following their return from the hospital for a UTI. R1 had been alert and oriented. HWD mentioned that S1 had reached out to S2, who then performed a bedside assessment of R1. S2 called and faxed R1’s PCP regarding the medication error and received instructions from the PCP on the care plan in response to the error. HWD stated that the facility held a care conference call with R1’s family to explain how the medication error occurred and what actions the facility was taking to prevent similar errors in the future.