Facility Evaluation Report

Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management - Annual Continuation visit to the facility above. LPA met with Ernest “EJ” Lewis, Acting Executive Director and explained the purpose of the visit.

LPA completed medication inventory and continued to review residents’ records for health screenings, Serious Illness/Injury reports, death reports, medication administration, appraisals, re-appraisals, admission agreements, and Physician’s reports.

Centrally Stored Medication Record: Record review and interviews revealed two prescribed medications were not listed on R1's Centrally Stored Medication Record.

Record review and interviews revealed the facility self-reported the following medication errors:

On 9/15/2023, Staff 1 (S1) discovered on 9/12/2023 PRN Acetaminophen bubble back was mixed into Resident 8’s (R8’s) routine medications. R8 was prescribed two tablets 3x/daily of Acetaminophen 500mg. S1 discovered R8 was administered 650mg of Acetaminophen instead of 1,000mg.

On 1/11/2024, CCL received an incident report stating on 1/4/2024 S1 removed R8’s Fentanyl 12mcg Patch that was applied on 1/2/2024 at 8:00 pm. Doctor's order states the patch is a 72-hour patch and should have been removed on 1/5/2024 at 8:00 pm. Per the incident report, S1 was "counselled with a Corrective Counseling Documentation, and was retrained on the process of administering fentanyl patch and was counseled to review of the physician order".

On 5/16/2024, CCL received an incident report stating on 5/7/2024, Resident 9 (R9) was transported via ambulance to the hospital due to being unresponsive. LIC624 states R9 received a diagnosis of “morphine overdose”.