Follow-up on corrections·November 26, 2025

On 11/26/2025, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to this facility to conduct a case management visit for deficiencies observed on 11/26/25. LPA met with Sherry Richard (S1) and Assistant Administrator Susan McClure, Administrator (S2) and stated the purpose of this visit. Upon record review of medications and Medication Administration Record (MAR) LPA observed, Resident 3 (R3) did not receive their scheduled in vega injection in November 2025 and licensing nor authorized person were notified. S3 stated medication was administered on 11/7/25, however it was not documented on the Medication administration Record (MAR). Licensing Regional Office nor R3s LPS conservator, were informed about the missed/delayed medication. S1-S3 stated they were unaware missed medications/refusals constitute special incident reporting. Guidance provided to S1-S3 regarding MARs and reporting requirements. LIC 9102s provided. No deficiencies were cited on this case management visit. An exit interview was conducted with Sherry Richardson and Susan McClure and a copy of these LIC 809 reports and LIC 9102s were left at the facility.