Incident investigation·April 10, 2025

On April 10, 2025, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with acting Executive Director . On 4/2/25, the department received an incident report of a medication error involving R1 on 3/26/25. On 3/26/25, R1 received a dose of hydrocodone at approximately 5:12 PM, from Generations Program Director (GPD), S1, who was filling in as PM shift met tech (MT). The report stated that the hydrocodone had been discontinued on 3/24/25, due to resident's physician determining that hydrocodone was causing R1 hallucinations. Records review and interviews conducted that on 3/26/25, R1 received a new medication to replace hydrocodone, Tramadol, at 8 AM, 2 PM and again at 8 PM. Interviews found that the error was not found until 3/27/25. Hospice was notified of the error. Interviews found that the main contributing factor for the error was a lapse in following of existing communications and documentation policies and procedures. R1 was not known to have been adversely effected by the error. 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. Civil penalty assessed. Report reviewed. Copy of report and appeal rights provided