Incident investigation·April 7, 2023

Licensing Program Analyst (LPA) Tuesday Cabiness met with Executive Director Johnny Ortiz, and Resident Services Director Venca Avivi informed them the reason of the visit. LPA conducted a case management pertaining to the a incident report that was submitted for resident # 1 (R1), and staff did not follow physician orders when administering the medication. LPA contacted the ED on 04/06/2023 to gather further information pertaining to the incident. According to the ED and Resident Services Director Venca Avivi, R1 was scheduled to have a dental procedure and was prescribed a medication, that was to administered the day before the procedure. Staff #1 (S1) did not have accurate information on the specific date as to when the medication was supposed to be administered to R1 and was given to R1 on the wrong date. The Resident Services Director reported to LPA, the correct information was not communicated to the medication technicians. LPA determined, facility staff did not follow the correct physician orders that was provided for R1. This is a health and safety risk to residents in care. A citation was issued during today's visit. Exit interview, copy of report and appeal rights provided to Executive Director.