Incident investigation·March 26, 2025

On 3/26/2025 at 09:38am, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced Case Management visit. LPA arrived at the facility, met with Administrator Carl Meyer, and announced the purpose of the visit. On 3/24/2025, LPA received a call from Administrator Carl Meyer stating there was a medication error, where Resident 1 (R1) was given Resident 2 (R2)’s medication. On 03/26/2025, Community Care Licensing received a self-report from the facility. LPA interviewed staff and reviewed records about the medication error. On 03/23/2025, at approximately 10:10am, Staff 1 (S1) gave R2’s medications including, 0.5mgs of lorazepam and 5mgs of oxycodone, to R1. S1 realized the error immediately and reported to Resident Services Director Maria Middleton. Staff called 9-1-1 around 12:15pm and R1 was taken to the hospital, where they observed R1 at the local Emergency Room. R1 returned to the facility on 3/23/2025. The facility was previously cited for a medication error on 02/27/2025, and the plan of correction included medication training for all staff that handle medications. The training was completed on 03/19/2025 and records reviewed showed S1 also completed the medication training on 03/10/2025. While reviewing R1 and R2's medications and Centrally Stored Medication Record(CSMR) LPA noted the lorazepam and oxycodone not listed on the CSMR for R2. LPA also noted 1 of each medication missing from their respective bubble packaging recorded on 3/23/2025. (Continued on LIC809-C) S1 was temporarily suspended until further investigation was conducted, upon return to work S1 will not handle medications. S1 gave facility notice of resignation with last day of 04/06/2025. Exit interview, deficiencies cited on 809-D, report given, and appeal rights given.