Follow-up·May 9, 2025

On 05/09/2025 at approximately 1:30 PM License Program Analyst (LPA) David Doidge arrived unannounced to conduct a case management visit regarding an Unusual incident report (UIR) that was reported to CCLD on 04/25/2025. LPA met with Tianna Henderson General Manager (GM) and explained the purpose of the visit. LPA Spoke with General Manager and the Medication Care Manager (S1). The UIR stated that the resident was given two (2) tabs instead of one tab as directed on the bubble pack. The incorrect dosage given was caused by an error from the pharmacy. The Pharmacy entered two (2) tabs as the dosage in the Electronic Medication Administrator Record (EMAR) and the bubble pack showed one (1). The Medication Care Manager (S1) caught the error when administering the dose and informed the pharmacy to have EMAR updated. Correct dosage has since been administered. Per GM retraining on medication was also performed. Resident’s spouse and PCP were updated. Resident was monitored with no negative side effects. No deficiencies observed or cited during this visit. . Exit interview conducted and a copy of this report provided