Facility Evaluation Report

Licensing Program Analyst (LPA) Albert Johnson arrived at facility unannounced to conduct a case management visit. LPA met with Administrator Arneatha Simon and explained the purpose of today's visit.

The facility self reported a repeat medication error as having occurred with resident 1 (R1). LPA interviewed Administrator Simon who confirmed that medication errors in the form of missed medication doses have occurred with staff 1 (S1). The Administrator also confirmed that the pharmacy did not refill the order which had zero refills and the doctor was not notified causing R1 to miss the medication for one day. It was also discovered that one of R1's physician's discontinued a medication on 11/26/2024 and prescribed another medication that has not been started. The order is pending approval from the insurance company. A new order has been requested to continue medication that was to be discontinued until the insurance.

LPA reviewed the Medication Administration Records (MARs) for R1 and verified the medication errors did occur over the course of the last two months. LPA also discussed the medication training protocols with the Administrator. The Limited Liability Corporation (LLC) has 4 Licensed Vocational Nurses (LVNs) on staff for this facility, direct care staff and Administrator for oversight of medication passes. Initial medication training and follow up in-service training is conducted with all employees as needed for the facility.

An exit interview was conducted and a copy of this report, appeal rights and a copy of the confidential names list were given to the Administrator.