Incident investigation·January 29, 2026

Licensing Program Analyst Manuel Monter conducted an unannounced case management incident visit regarding a incident report. . LPA met with Administrator Kurt Gursu, On January 12, 2026, the Department received an incident report regarding R1. The incident report stated, on January 8, 2026, two staff members (S1 and S2) brought the incorrect resident to a scheduled immunization. Staff member incorrectly brought resident R2 instead of R1. No adverse reactions were reported. R1's responsible party and physician were notified. On January 29, 2026, LPA Manuel Monter interviewed ADM. ADM confirmed that the issue regarding this incident was that staff S1 and S2 made a mistake and took R1 to R2's scheduled immunization. ADM stated the staff told him, they made the mistake because R1 and R2 have similar names. ADM stated both staff were given counseling and had additional training assigned. LPA requested a copy of the documented training. No deficiencies cited during today's visit. A technical violation was provided. This report was reviewed with Administrator Ugur (Kurt) Gursu and a copy of the signed report was provided.