Incident investigation·June 3, 2025

On 06/03/2025 at 1:30 PM, Licensing Program Analyst (LPA) Ardalan Gharachorloo conducted a case management visit in regard to special incident report received on 05/22/2025. LPA met with Program Supervisor, Precious Yepez and Explained the purpose of the visit. LPA received special incident report on 05/22/2025 for R1. Special incident report revealed that at 9 AM, while the registry nurse was doing medication check, she noticed R1’s antibiotic was not given for R1’s 1 PM dose on 05/21/2025. LPA interviewed S1 who stated that the physician was immediately notified and instructed the registry nurse to have staff continue with the next dosage and add the missed antibiotic for 05/25/2025. LPA also interviewed S2 who stated when she was doing med check, she noticed that the dosage of the medication was not given to the resident. S2 further stated that one of the staff was doing laundry and forgot to give the antibiotic for R1’s 1:00 PM dose on 05/21/2025. S2 stated that there was no change of condition with the client. LPA reviewed R1’s MAR’s and documents related to R1’s care. Exit interview conducted and a copy of this report provided.