Incident investigation·May 28, 2024

On 5/28/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Darius Stir. The department received an incident report for an incident involving R1. On 5/22/24, staff found R1 to be in their bed at 6:30 AM and unresponsive. Emergency services were called and transported R1 to an area hospital. R1 was found to have had a medication overdose and was found to have a different resident's medication bottle in R1's pocket. (At the time of this report the other resident to whom the medication were prescribed has not been identified. LPA and Darius toured the facility to include, R1's bedroom, staff room location, where keys are kept and the kitchen/ medication areas. By reports, the kitchen was locked and medication cabinet keys were hung in the kitchen. R1 was suspected of accessing the kitchen through a window/ counter between the kitchen and living room. There were no awake overnight staff on the night of 5/21/24. Live-in staff were present but not alerted to need assistance to residents. Approximately 2 weeks prior to 5/22/24, R1 was suspected of possible accessing keys and having entered the staff office. The keys were moved to the locked kitchen. R1 has not yet returned to the home. Licensee will submit the following records to CCL: R1's LIC 602, Pre-appraisal and LIC 625 currently on file. Licensee will request R1 release hospital records for 5/22/24 emergency and hospitalization. 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 report and appeal rights provided