Facility Evaluation Report

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a case management - incident visit. LPA met with General Manager (GM) JP Rollet. LPA stated the purpose of the visit.

The purpose of the visit was to address 2 medication errors that occurred on 7/25/2025 and 4/16/2026. On 7/30/2025, the Department received an incident report regarding a medication error on 07/25/2025 involving Staff S1 giving resident R1 another resident's medication. The incident report states S1 "accidentally gave the medication to another resident." S1 reported the medication error to management, and 911 was called. R1 was taken for observation to the hospital, and returned back to the facility the same day with no injuries. The reports states R1 was monitored by staff for changes in condition after the medication error, and R1's family and primary care physician were notified.

On 9/19/2025, a Case Management visit was conducted. During visit, LPA requested copies of the following documents: Disciplinary Notice, In-Service Training Records, physician's reports, Service Plans, Centrally Stored Medication and Destruction Records, and Medication Administration Records (MAR).

On 4/21/2026 the Department received an incident report regarding a medication error on 4/16/2026, involving Staff S2 giving Resident R2, an incorrect dose of medication.