Incident investigation·December 22, 2021

Licensing Program Analyst (LPA) Fernandes-Goes arrived unannounced with the purpose of closing a complaint investigation. During subsequent complaint investigation LPA learned there are related deficiencies observed during the visit. LPA met with Cynthia Virata - Administrator. Following item were observed during investigation visits: LPA observed during interviews and resident's files review on 9/29/2021 & 11/22/2021 that facility has had a medication error on 9/27/2021. Resident R1 had a medication order discontinued by doctor on 9/20/2021 & 9/24/2021. Medication technician staff S1 dispensed discontinued order of 3 x 75 mg Clozapine and new order of 3 x 100 mg Clozapine dated 9/20/2021 instead only 3 x 100 mg of Clozapine until 9/26/2021. As per administrator, doctor and family member were contacted. Staff S1 received retraining on Relias on 10/6/2021. Per staff S1 interview, discontinued doctor's orders for 3 x 75 mg Clozpine wasn't submitted to the facility until 2 days later of new order. No deficiencies cited during this inspection.