Incident investigation·February 7, 2025

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 09:37 AM to conduct an unannounced Case Management visit at the facility today. LPA met with facility Executive Director (ED) Grace Hartnett entrance interview conducted and the reason for the visit was explained. The purpose of today’s visit was to follow-up on a self-reported incident that occurred on 02/02/2025. During today’s visit between 09:45 AM and 10:45 AM LPA conducted a brief physical plant tour, interviewed the Executive Director and The Director of Assisted Living Yamilette Capilla. Additionally, LPA conducted a file review and obtained copies of pertinent documentation. The self-reported incident report stated that Resident #1 (R1) had self-administered opioid medications and suffered a medical emergency. ED stated that R1 had snuck medications into the facility without staff’s knowledge. ED stated that R1 is enrolled with the facility’s medication management program and is not permitted to store their own medications. ED stated that the facility has implemented room sweeps, pauses on deliveries to R1’s room, and additional care checks for R1 to prevent this behavior. Additionally, ED has had conversations with the responsible party (RP) for R1 in an effort to mitigate this behavior in the future. LPA was unable to interview R1 at the time of the inspection as they were out of the facility. Further investigation is needed prior to determining if citations are warranted. LPA will return at a later date to inform ED of the outcome of the investigation. No deficiencies were cited during today’s inspection. Exit interview conducted and copy of the report was issued.