Incident investigation·December 16, 2025

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced to conduct a case management visit regarding an incident report received on 12/15/2025 regarding a medication error made. LPA reviewed medications of residents and discussed with Executive Director Patty Uclaray the changes in procedures for medication passing during visit. On 12/11/2025, Resident R1 was given the wrong medication during morning medication pass by Staff member S1. Staff immediately called poison control and monitored R1 closely. Staff contacted R1’s responsible party who declined to have R1 sent to emergency room for evaluation. No negative outcome noted. Although a medication error was made, it appears that the staff reacted immediately to follow up and ensure the resident's safety. Staff has been reassigned permanently. As a result of this visit, a deficiency is being cited on 9099- D page. As a result of medication error, a civil penalty is being assessed in the amount of $250.00. Appeal rights given. Exit interview conducted.