Incident investigation·July 18, 2024

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to obtain additional information for an incident report recently submitted to the Department. LPA met with Henry Cole, Administrator and stated the reason for the inspection. The facility submitted an incident report on 7/16/24 related to (1) pill of Norco that was discovered missing from the medication cart on the morning of 7/12/24, when a routine medication count was conducted. The missing medication was thoroughly looked for in the medication cart and surrounding areas, but was not found, so the incident was immediately reported to the Administrator and management. All Med-Tech staff who worked on/around 7/12/24, were interviewed. The one Med-Tech staff (S1)who worked on NOC shift was questioned more in detail but was not able to explain how the medication went missing. Staff (S1) did not want to be interviewed, walked out of the community, and submitted her resignation. Resident (R1) did not miss any doses of PRN Norco 5/325 mg. The camera in the medication room wasn't able to capture the details of how the medication disappeared; so there is only circumstantial evidence that (S1) was responsible for the missing tablet. In May 2024, the facility increased its medication security protocols by installing cameras in/near the medication rooms, requiring that keys be signed in/out by each staff at shift change, and not permitting keys to leave the facility. The facility continues to complete all required narcotic counts to ensure medications are kept secure. It appears the facility followed its medication protocols. There are no deficiencies cited in this report. Exit interview. Copy of report provided to the Administrator.