Incident investigation·October 30, 2025

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced Case Management Visit-Incident on 10/30/2025, stemming from incident report received on 10/16/2025. LPA was greeted by Director of Nursing Nicole Stinson and the purpose of the visit was explained. During today’s visit, LPA Gonzalez toured the facility’s medication room, obtained staff and client rosters, obtained copies of documents related to the incident, interviewed staff #1-3 (S1-S3) and residents #1-2(R1-R2). According to LIC 624- Unusual Incident/Injury Report received on 10/16/2025, staff self-reported that during a routine medication audit, it was discovered that R1 was not administered morning medications. Staff interviews and record review revealed the facility schedules two (2) med techs per shift and one (1) overnight. On the morning shift of 09/02/25, S2 observed morning medications had not been administered for R1 on 09/01/25. S2 immediately informed S1. R1’s doctor and family were also notified. R1 was monitored and did not have any adverse reaction and remained in stable condition. No further action is required at this time. LPA Gonzalez may return to gather additional documents. No deficiencies were cited during today's visit. Exit interview was conducted. A copy of this report was provided to Director of Nursing Nicole Stinson.