Follow-up·October 26, 2022

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 10/26/22 to conduct a case management inspection to follow up on a recent medication error at facility. LPA met with facility administrator Madelyn Rojo and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted facility and completed a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn surgical mask. LPA was screened by facility staff upon entry. During record review and staff interviews, it has been revealed that facility kept the proper record for centrally stored medications for all residents however there was a missing signature on MAR sheet for R1s medication after the medication has been administered. Facility will implement double signature sheet for medication administration to avoid such errors in future. No citations issued today. Exit interview conducted with administrator. Copy of the report provided.