Incident investigation·March 3, 2025

At approximately 2:30PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to a special incident report submitted to the Department on 02/18/2025. LPA met with Executive Director Angela Stevens and reviewed records. The incident was in regards to a staff member accidentally pouring urine, from a juice bottle, into a cup for a resident during a medication pass. This facility does not utilize a medication cart during medication pass. The Medication technician bring medication to each residents room. The medication technician entered the residents room to assist with medications and observed several bottles of juice on the counter top. The resident had recently received the juice from a family member. The medication technician poured what appeared to be apple juice from one of the open bottles and gave it to the resident. Resident took the medication and drank the liquid. Resident told staff that the liquid was their urine. Based on records reviewed, resident lives in the assisted living section of the building and does not have a dementia diagnosis. There were no prior incidents where resident used a bottle to urinate in. Staff immediately removed the bottles from the residents room. Resident responsible person was notified. Facility placed resident on alert charting and updated their care plan. No citations issued during todays visit.