Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to conduct a Case Management visit. LPA was greeted by concierge. Tristan Amari, Business Office Manager arrived later.

On 7/10/25 CCL received an Incident Report indicating that facility had experienced a medication error for seven [7] residents on Monday, 7/7/25 ( deficiency cited, see 809D ). Later the same day, CCL received another Incident Report indicating a resident (R8) may have also received the wrong medication on 7/7/25.

LPA interviewed Health and Wellness Director (HWD) Jody Livingston and Health Services Assistant (HSA) Pam Brown about medication errors that occurred on 7/7/25.

Per HWD and HSA, the medications errors occurred due to Med Techs pre-pouring medication. As pertains to this incident there were two instances of pre-pouring ( deficiency cited, see 809D ). On the morning of 7/6/25, staff (S1) pre-poured medications to be administered on the morning of 7/7/25. On the evening of 7/6/25, staff (S2) pre-poured medications to be administered the evening of 7/7/25. The two [2] boxes of pre-poured medications were then placed in the medication closet, to be administered the next day. On the morning of 7/7/25, staff (S3) mistakenly pulled the evening medication box and administered evening medications to residents R1, R2, R3, R4, R5, R6, and R7. Later in the morning of 7/7/25, HSA was notified that resident R8 was not given her medications at all that morning. HSA then went to R8's room and administered their morning medications. So, R8 did receive her morning medications on the morning of 7/7/25; thereby receiving them at approximately 10:30am instead of at 8:00am as scheduled.