Incident investigation·April 16, 2025

On 4/16/25 at 2:30 p.m., Licensing Program Analyst (LPA) Greg Clark and Ardalan Gharachorloo arrived unannounced to conduct a case management visit on this date to provide technical assistance. LPAs received special incident report regarding numerous medication errors that occurred on 4/1/25 for 23 residents. The errors happened when the facility was switching pharmacies. LPAs spoke with Executive Director and reviewed the report with her. LPAs also toured the medication room and observed the current system of dispensing medications and storage. None of the residents experienced any side effects from the missing medications most of which where over the counter medications. Interview with the Executive Director revealed that the issue has been resolved and there have been no further medication errors occurred. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.