Incident investigation·March 27, 2025

On March 27, 2025, Licensing Program Analyst, Kevin Mknelly arrived at 10:20 AM and met with Administrator/ Director, Nathan Condie. The purpose of the visit was to review recently reported incident. On 3/20/25, the department received an incident report of medication error for R1 on 3/14/25. It was reported that medication technician (med tech) S1 mistakenly administered a once per day blood pressure medication at 8:00 PM though the medication had already been correctly administered on 3/14/25 at 8:00 AM. The error was reported to the facility's nurse and monitoring was increased for the resident. At approximately midnight, R1's blood pressure triggered a call to emergency responders. Responders monitored the resident and resident did not require hospitalization. R1 sustained no further negative effects. A deficiency is noted for this medication error. Falls by R2 were also discussed. R2 experience 4 falls, some with minor injuries, between February and March 2025. On 3/7/25, R1 was admitted to rehabilitation for improved conditioning. While in rehab., R1 passed away from causes unrelated to care at this facility. No deficiency was cited for this issue. While at the facility, LPA and Director observed and discussed strategies for managing residents with wandering and exit seeking. Issues discussed involved possibilities of limiting egress from certain doors from memory care to the courtyard. LPA encouraged Director to discuss possible alterations to exit with the area fire Marshall for approval. 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. Report reviewed- copy of the report and appeals rights provided.