Incident investigation·May 20, 2025

Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Gabriela Castro conducted an unannounced Case Management Visit-Incident on 05/20/2025, stemming from incident report received on 05/02/2025. LPAs were greeted by Director of Health Services-Minerva Naranjo and explained the purpose of the visit. Case Management findings: On 05/02/2025, LPA Ramirez received an Unusual Incident/Injury Report (LIC 624) regarding medication error that occurred on 05/01/2025. Per Unusual Incident/Injury Report (LIC 624) dated 05/01/2025, staff#1 (S1) erroneously dispensed another resident’s scheduled medication to resident#1 (R1). Staff immediately notified R1’s responsible party and R1’s primary care physician of the medication error. R1’s primary physician ordered facility staff to monitor R1’s blood pressure, report any abnormal results and skip AM medications till 05/02/2025. Facility staff later reported R1’s blood pressure to R1’s primary care physician and R1’s primary care physician deemed those results were normal. Facility staff reported R1 did not have any adverse reactions throughout 05/01/2025. According to Unusual Incident/Injury Report (LIC 624), S1 would be receiving in-service re-training on medication administration. On 05/20/2025, LPAs requested to review S1’s in-service training on medication administration completed after 05/01/2025. LPA’s reviewed completed in-service re-training for S1 with a final completion date of 05/07/2025. No deficiencies were cited today. Exit interview was conducted. A copy of this report was provided via email.