Incident investigation·March 7, 2024

Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility and was greeted and granted entry by Receptionist Ami Tynes. LPA then met with Diane Navarro Vice President of Operations. LPA stated the purpose of the inspection. LPA stated they are conducting a Case Management inspection to follow up on medication errors self-reported by the facility. The incident reports were received by Community Care Licensing (CCL) on 2/21/24 and 2/22/24. These reports indicate the following: 1. Med Tech (MT1) did not give scheduled medication to Resident (R1) as ordered on 2/16/24 2. MT1 did not give scheduled medication to R1 as ordered on 2/17/24 3. MT1 applied the wrong cream to R1's abdominal fold on 2/20/24 LPA interviewed the VP of Operations and determined the medication errors were made by the same staff member. VP stated the facility decided to terminate the Med Tech due to multiple medication errors made in less than a week. VP stated R1's family visits R1 daily. VP stated the facility has been in communication with R1's family throughout the medication error and MT1's termination. LPA requested copies of the following documents: 1. R1's Admission Agreement 2. R1's February 2024 physician's orders 3. R1's February 2024 MAR 4. R1's alert charting 5. February 2024 CP/MT Schedule 6. Email: Incident Summary Report 7. Termination Form for MT1 8. Internal Email RE: MT1's Termination. Based on record review, LPA determined the facility terminated MT1 on 2/21/24. LPA determined that the facility took timely and appropriate action to correct the errors made. No deficiencies were noted from today's inspection. An exit interview was conducted with the VP of Operations and a copy of this report was provided.