Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management - incident visit. LPA met with Operations Manager, Josh Fane.

The purpose of the visit is to follow-up on an incident that was reported to the Department on 04/14/2025 regarding resident (R1) who had over-dosed on medication.

During visit, LPA interviewed 2 staff members and reviewed a video footage of the incident. Documents were obtained to include R1's physician's report and appraisal/needs and services plan.

On 04/13/2025, it was reported that approximately 09:40pm R1 walked into the office to take his/her PM medications with staff. During self-administration of R1's medications, staff noticed that R1 tried to pocket a pill and asked R1 not to do that. In the video footage, it shows R1 quickly placed his/her medication pills inside his/her pocket while staff quickly looked away for about 2 seconds at the computer screen where the electronic medication administrator record is located. R1 dropped a pill on the floor and staff found and discarded the pill found on the floor.

When R1 exited the medication room, staff immediately counted R1's medications where it was observed that R1 was missing a large amount of pills. See LIC809-C.