Facility Evaluation Report

Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on 07/25/2024 at 9:00 AM. LPA Martinez met with Andrea Armstrong and explained the purpose of the visit.

The purpose of the visit today is to conduct a quarterly visit. LPA Martinez followed up with the following:

Staffing Concerns : Job Fairs conducted and continuos hiring.

Medication Errors: A medication error was reported to Community Care Licensing Department (CCLD) by the facility.

Medication Audit: A medication audit was completed on July 18, 2024.

Reporting Requirements: The Department has received incident reports from the facility.

Medication Training : June 12, 2024 and July 15, 2024.

Facility Polices Regarding: Assessments, Monitoring of residents, Change in condition, Medication errors. Polices provided to CCLD.

Medication Error: Resident (R1) was given the wrong Metoprolol SUCC ER dosage. Per facility medication error communication note, R1 was administered the wrong dosage from June 06, 2024 to July 09, 2024. During the error medication review, it was learned R1 Medication Administrator Records (MAR) were not maintained. The February and May MAR had missing staff administration signatures: February 07, 2024-Metoprolo; May 23 and 25, 2024. LPA Martinez reviewed the MARs' caregiver notes for the missing administration signatures information, and there were no notes. LPA Martinez also requested new medication orders and discontinued medication orders for Metoprolol. The requested medication orders were not provided during today's visit. LPA Martinez was informed by staff that the orders would need to be requested from pharmacy. Continued...