Incident investigation·April 21, 2025

Case management made out to the facility due to received incident report from facility regarding medication errors with residents and caregiver involved with the incident. Discussed with Executive Director (ED) - Emily Venegas concerns involving this matter. Executive Director (ED) - Emily Venegas did provide documentation of Training conducted with staff right after the incident occurred. Records do show past incidents of medication, ED stated that there is zero tolerance policy for medication errors. Since incident reported to CCL staff person has been put on notice. Facility has taken steps to prevent medication errors, resident was monitored and there were no adverse reactions reported. LPA M Vega discussed the issue with Executive Director. No deficiencies cited at this time since facility and facility personnel took the necessary and crucial steps in ensuring proper resident care and supervision. Resident doctors were notified along with resident responsible parties with incidents and was well documented and sent into CCL by appropriate due date of reporting time frames. Follow up has been done with resident doctors as well.