Incident investigation·April 4, 2025

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management - Incident visit in regards to an Incident Report the Department received on 02/05/2025. LPA met with Administrator (ADM) Matt Zahodne and stated the purpose of the visit. On 02/05/2025, the Department received an LIC 624 Incident Report stating resident R1 was administered the wrong medication by Staff S1 on 02/02/2025. Per Report, R1 did not have any bad interactions and R1's responsible party and physician were informed. During today's visit, LPA Rai conducted interviews with 2 staff, including ADM. S1 stated he/she administered resident R1 the medication for resident R2. S1 admitted the names of R1 and R2 were similar and didn't realize the mistake until S1 was administering medication to R2 and realized the medication cup was empty. S1 and ADM stated R1 did not have any reaction to the medication and there are no new orders for R1. Based on review of R1's facility records, R1's physician was notified of the incident and provided the vitals log of the resident following the incident. R1's physician noted the incident and did not give further instructions. Per R1's progress notes, R1's family member was informed of the incident. LPA Rai reviewed S1's training logs on medication training which includes Providing Medication Assistance and Avoiding Common Medication Errors. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. ADM stated S1 and other staff who are responsible to administering resident's medications were provided in-service training and additional hands-on training. ADM will provide in-service training records by Monday, 04/07/2025. At this time, LPA Rai determined this case management needs further investigation. This report was reviewed with Administrator (ADM) Matt Zahodne and a copy of the report was provided. .