Incident investigation·July 1, 2025

On 07/01/2025 at 2:25 PM Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported missed medication that occurred on 06/12/2025. Health Services Director, Leslie Ibo self-reported the incident on 06/19/2025. LPA met with General Manager, Ryan Turner, and explained the purpose of the visit. LPA received an incident report that on 06/12/2025 for Resident 1 (R1) that revealed that R1 was not administered the insulin dose in the morning because the second safety on the needle remained intact causing the missed dosage of the medication. R1 was then given the lunch dosage after the incident. LPA reviewed Physician’s Fax Report dated 06/12/2025, Insulin Staff Training, Progress Notes, Aegis Medication Incident Report and June Emergency Paper Medication Administration Record (MAR). Progress Notes indicated that the facility contacted the appropriate parties such as R1’s physician and family. Progress Notes also stated that R1 was placed on monitoring and did not show any side effects from the missed medications. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with General Manager Appeal Rights and a copy of this report provided.