Facility Evaluation Report

On January 02, 2025, at 10:40 AM Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to conduct a Case Management – Incident visit regarding (3) separate incidents that occurred on 12/23/2024, 12/22/2024, and 11/27/2024. Upon arrival, the LPA was greeted by the Executive Director (ED), Flavio Silva. The LPA disclosed the purpose of the inspection.

1) For incident #1, happened on 12/23/2024, resident (R1) was given wrong medication and resident (R2) was not given medication.

On 01/02/2025, LPA Jain interviewed residents (R1 and R2), two staff members Executive Director (ED) and Resident Services Director (RSD).

LPA Jain interviewed R1. R1 stated on 12/23/2024 morning, a nurse came to their room, didn’t turn on the lights, and gave the medication to R1. R1 ate the medication. R1 stated that their regular nurse (S1) came back after some time with medication again. R1 told the nurse they already ate it. The nurse told R1 nothing is marked on the computer and went out of the room. R1 picked the empty cup from the garbage and saw #241 written on it, which was not R1’s room number and went to ED’s office and told ED what happened. ED told R1 that they would investigate. R1 further stated that the nurse who gave the medication to R1 didn’t mark the medication given to R1 and luckily the medications were same and R1 didn’t feel any side effects of the medication given. R1 told their family members about this incident.

LPA Jain interviewed R2. R2 stated that they have no idea if medication was not given to them on 12/23/2024 morning. R2 said nothing happened and its fine if they missed the medication.

LPA Jain interviewed ED. ED stated that Incident happened on 12/23/2024 morning. RSD was working as med tech during the overnight shift from 12/22/2024 8:30 PM to 12/23/2024 7:30 AM. On 12/23/2024, around 9:40 AM, R1 came to ED’s room and said they took the medicine from room #241 while holding the cup.