Incident investigation·November 6, 2024

On 11/6/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Director, Jessica Sanders. On 11/5/24 the Regional Office received incident reports for the following incidents: Incident 1- On 10/30/24, medication technician, S1, notified managers that a medication documentation irregularity was found. The incident involved R1 who was supposed to receive a daily full tab of a controlled medication. The incident report noted that R1 was documented to have received a half tab of the medication instead of the prescribed full tab 10/7/24- 10/30/24. R1 was unharmed as a result. R1's physician was notified and corrective action was taken with the three staff who had made the error. LPA reviewed records and conducted interviews where it was found that staff deviated from facility policies and did not follow medication training that resulted in R1 not receiving medication assistance for medications as prescribed. Incident 2- On 11/3/24, at approximately 1:30 PM, staff discovered R2 to be missing. R2 has a known history of attempts to leave the memory care without physician's recommended assistance when leaving. The care plan in place was for staff to maintain "eyes on" for R2 during waking hours. In this incident it is unknown how R2 left unaccompanied. LPA conducted interviews with R2, Administrator and 2 caregivers that were present on 11/3/24. Interviews found that while staff were aware of R2's exit seeking behaviors, there was not a concrete plan for how the staff present would maintain eyes on R2. On 11/3/24, R2 was found by local police a short way from the facility and was returned unharmed. This is the second such event for R2. It is found that there was not an adequate number of direct care staff to support each resident’s safety needs as identified in his/her current appraisal. The facility has since added additional care staff to PM shifts. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. The citation for insufficient staff for dementia care is the third within 12 months. Civil Penalties are applied. Report reviewed. Copy of report and appeal rights provided