Incident investigation·April 9, 2026

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit and met with Executive Director Assaid Zeid, informing him of the purpose of the visit. The purpose of today’s visit was to address and gather information regarding an exception request submitted to the Department for approval to retain a resident requiring intravenous (IV) antibiotic treatment. Based on information obtained during today’s visit, the Executive Director (ED) reported that the exception request was submitted on short notice due to a family emergency involving Resident 1 (R1). R1’s family requested that the facility retain the resident for continued treatment while they addressed the emergency. The request was submitted to the Regional Office and was pending review and approval by the Department’s Nurse Consultants. Due to the short notice and the Department not yet issuing approval or denial, the family elected to retain R1 without assistance from the facility. R1 was subsequently re-admitted to the facility on 04/08/2026 without further treatment. During the visit, LPA also addressed recent incidents involving medication errors. According to an incident report dated 02/09/2026, the facility hired a Licensed Vocational Nurse (LVN) through a registry to administer medications. The LVN erroneously administered another resident’s medication to Resident 2 (R2). Following the incident, the LVN was relieved of their duties, and the facility discontinued use of that staffing registry. Regarding a more recent medication error on 04/09/2026, facility staff mistakenly administered medication to Resident 3 (R3). In response, the ED and Health Services Director conducted in-service training and implemented additional staffing during morning and evening medication administration shifts. LPA requested copies of the training documentation and a list of staff who attended. The ED also reported that additional procedural changes will be implemented for newly hired medication technicians. Citation and civil penalty assessed, appeal rights provided, exit interview, and copy of the report to ED.