Facility Evaluation Report

Licensing Program Analyst (LPA) K. Hiratsuka, conducted this unannounced case management visit. This is in response to an issue LPA learned while conducting a change of ownership prelicensing visit.

LPA learned a resident went without a blood pressure medication since March 11, 2026. The facility staff notified the doctor on March 11, 2026, which was the day of the last dose. The facility received a fax back that only had a doctor's signature. The refill arrived on March 26, 2026 to the facility. LPA was informed when the refill arrived it was placed in the overstock supply instead of being entered in correctly as the refill. The error was discovered today.

This is the second citation within a twelve month period. Therefore, an immediate civil penalty of $250.00 was issued today and shall accrue at $100.00 per day until the licensee submits a written plan of correction and proof of training on how they shall ensure all medications are accounted for.