Incident investigation·April 12, 2023

On 4/12/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Case Management- Incident inspection. LPA met with Community Relations Director (CRD), Jane Scapparo, and explained the purpose of the visit. The purpose of the visit is to follow-up on two unusual incident/injury reports that was submitted to Community Care Licensing (CCL) on 03/31/2023. Incident report indicated on 03/28/2023, a quarterly audit was conducted by Omnicare Pharmacy, per community request. During the audit, it was found that residents (R1 and R2), had not been receiving their medications for administration. The facility requested for R1's and R2's medication refills. R1 and R2's physician's were notified. R1 and R2 were observed by staff for 48 hours for any changes related to missed medications. On 4/5/2023, all of the medication technicians will receive mandatory training on the process of reordering medications and procedures to follow when a medication does not have any refills. LPA interviewed CRD regarding the two incident reports. CRD stated facility is currently switching over to use online eMARS which will be easier to staff to track medications. LPA requested for audit documents for review. At this time no deficiencies are being cited. Exit interview conducted and report provided.