Incident investigation·November 5, 2025

Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday November 5, 2025, to conduct a case management due to an incident report received by the Department on 11/2/2025. LPA met with Natalie, Resident Care Coordinator, and explained the purpose of the visit. LPA learned the following: there are currently 9 residents (3 in AL, 6 in MC) whose medications are not bubble packed. Each shift must do a narcotic count prior to leaving/starting their shift. On Sunday November 2, 2025, the AM Med Tech for memory care observed 5 pills in R1's non bubble packed narcotic bottle which were a different medication. Med Tech notified Health Services Director and Executive Director. R1 had not received this PRN narcotic since 8/3/2025. Additionally, LPA spoke with HSD and ED on the phone for additional information. Per ED, all med techs have been interviewed. All residents will be required to have all medication bubble packed moving forward. Facility sent out letters notifying families that this will be the resident/POA's financial responsibility beginning 2/1/2026. The facility will pay for the cost to bubble pack medications until 2/1/2026 for the 9 residents. LPA obtained a copy of R1's Drug Administration Record and PRN medication ability determination form. ED will send LPA a detailed summary of the investigation by end of day 11/7/2025. Additionally, HSD will provide additional training for all med techs. Health Services Director will provide LPA a copy of training when complete. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Executive Director.