Non-compliance follow-up·March 27, 2025

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit regarding a Special Incident Report (SIR) that was submitted concerning eight (8) residents who were not administered their prescribed medication. LPA met with Executive Director Myla Belson and informed her the purpose of the visit. According to the SIR, the facility’s medication protocols were reviewed, and the error was identified and addressed promptly. Administrative staff immediately notified the residents' families and primary physicians, and all affected residents were placed under immediate observation. It was reported to LPA that no adverse effects were observed. LPA interviewed staff and the Executive Director and reviewed resident records. Notably, the facility was placed on a non-compliance plan dated 12/15/2022. Additionally, the reports cited the facility for violations related to reporting requirements, resident injuries, unexplained falls, and medication errors, including a questionable death. It was further documented that legal action maybe taken against the facility. Since the date of the Non-Compliance Conference (NCC) on 12/15/2022, and up to today's date, the facility has received six (6) complaints and five (5) case management visits. Two (2) of these visits, on 04/07/2023 and 10/30/2024, involved residents being administered the wrong medication. Another case management visit on 06/24/2024 was related to a failure to report. During today’s visit on 03/27/2025, involved eight (8) residents who missed their daily medication. According to the information obtained, on 03/17/2025, the disbursement of noon medication was missed and not given to residents. Staff identified the error and notified the appropriate administrative staff. Based on today's findings, LPA will recommend that the initial non-compliance plan dated 12/15/2022 be extended for an additional two (2) years and that another (NCC) meeting be scheduled at the local regional office (RO). LPA will discuss recommendations with management, and further review is required at this time and LPA will follow up with the ED. Citation issued, civil penalty assessed, appeal rights, and copy of report provided to ED.