Incident investigation·July 21, 2021

Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 07/21/2021 to conduct a case management visit regarding an incident report Community Care Licensing (CCL) received on 07/19/2021, LPA met with Executive Director (ED) Dana Stansel and explained the purpose of the visit. Prior to initiating the case management, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by facility staff upon entry. Incident report received on 07/19/2021 was in regards to an incident that occurred on 07/15/2021, resident (R1) was inadvertently given the wrong medications. Med-tech noticed the mistake immediately and the proper parties were notified, R1 was transported to the hospital and no adverse reactions were suffered. LPA and ED discussed the incident in further detail, R1 was mistakenly handed the wrong residents medications after the med-tech had poured them and addressed another residents behaviors in the memory care unit. The med-tech was issued a final written warning, provided with additional training, and shadowed on the next shift to ensure no errors were made. A deficiency is being cited as a result of today's visit and is on the attached LIC 809-D. Exit interview conducted, appeal rights provided, and copy of report left at the facility.