Incident investigation·March 22, 2024

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit in response to the Unusual Incident Report (UIR) submitted by the facility. UIR indicated that at 12:26 p.m. on February 8, 2024, Reflections Coordinator (S1) was notified by care manager (staff) that there were discrepancies with residents' narcotic medications. After S1 confirmed that the medications in the containers were incorrect, S1 reported to the Wellness Director (WD) who in turn reported to Executive Direction (KED) Cayia Henry. WD and ED immediately launched an investigation and in-service on narcotic count and recognition initiated to all med-techs. ED notified Local Law Enforcement, and Controlled Substance Count documented. On this day, March 22, 2024, LPA conducted interview and obtained copies of documents. No deficiency cited. Exit interview conducted, and copy of this report provided.