Follow-up·October 23, 2024

On 10/23/24 around 9:45 AM, L. Holmes Licensing Program Analyst (LPA) arrived unannounced to conduct a case management regarding an Unusual/Incident Reports (UIR) and Death Report (DR) for Resident (R1) LPA met with Lurinza Bean, Licensee (S2) and explained the purpose of the visit; ADM Brittany White arrived shorlty after. On 10/01/24 ADM reported the following, “On 9/26/2024 R1 was having a virtual MD appointment, and We Care is requesting the primary care MD approve a request for a hospice evaluation due to recent decline. During appointment, the MD verbally instructed that Licensee, S2 to send R1 to ER for evaluation due to noted change in condition . 911 was alerted. Upon arrival to community, they successfully transported pt to ER for further medical evaluation . Pt conservator informed. Permission given for Hospice Evaluation Continue communicating to St. Mary's Hospital that pt needs a hospice evaluation.” During the visit on 10/09/24, LPA reviewed the file for R1 including but not limited to R1's After visit summary for 09/2024 & 07/2024, and Identification and Emergency Information. On 10/14/24, ADM sent R1’s Physician’s Report (LIC 602) and DR for death dated 10/13/24. After careful review of R1’s medical history with LPM Y. Flores-Larios, LPA returned to review R1’s Medication Administration Records (MAR) and Centrally Stored Medication and Destruction Record )LIC 622) for accuracy. ADM stated that she will provide additional faxes and emails to support the change in R1's condition. -At around 10:59 AM, LPA found that the records were inaccurate for a sample of seven (7) out of eleven (11) medications on the MAR and LIC 622 when compared to the after visit summary medication list on 06/04/2024. Deficiencies are cited on the attached LIC 809D. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided to Licensee, Brittany White, Administrator