Incident investigation·October 9, 2025

Licensing Program Analyst (LPA), Mayra Cota, conducted a Case Management – Incident visit today to follow up on incident report received by the department. LPA met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained. According to Special Incident Report (SIR), a medication error was noted on 9/25/25 in which Resident #1 (R1) was administered Oxycodone three times within a six-hour period. The order for Oxycodone is for every six hours for R1. According to Staff #1 (S1), a staff who was monitoring documentation informed S1 that a medication error was noted on the narcotic count sheet from 9/25/25 for R1. S1 checked R1’s QuickMar entries and found that Oxycodone was administered at 4:00 p.m., 7:00 p.m. and 10:00 p.m. S1 indicated that review of R1s QuickMar confirmed that R1 received excessive dosage of Oxycodone medication on 9/25/25 between the noted time period. S1 stated, R1 had to be closely monitored by staff to ensure R1 did not experience adverse effects from the medication. R1’s vitals were closely monitored and R1’s physician was notified immediately about the incident. The incident was also reported to the ombudsman and licensing. S1 further indicated, R1’s physician ordered a temporary suspension of R1’s Oxycodone and doses were resumed once R1’s vitals stabilized. Interview with Staff #2 (S2) indicated, S2 became aware of the medication error through staff communication and was assigned to conduct check of vitals on R1. S2 further indicated that during wellness checks, R1 slept soundly, and later was observed walking around the facility. S2 also stated that R1was observed returning their food tray which showed indications that food was eaten by R1. ***Continues on LIC 809-C S1-S2 stated, once R1 was observed to continue with normal activity, med-tech staff resumed administration of R1’s Oxycodone on 9/26/25 at 10:00 p.m. According to S1, R1 was informed about the medication error and R1 agreed to have the medication paused while staff observed R1. Review of R1’s Controlled Medication Count Sheet, indicates Oxycodone was administered on 9/25/25 at 4:00 p.m., 7:00 p.m. and 10:00 p.m. S1 stated, they conducted meetings with the staff who administered the medication incorrectly to R1 and corrective actions were discussed and set in place. LPA conducted interview with R1 during today’s visit. R1 indicated, staff have been managing their medication correctly after the incident on 9/25/25 and has no concerns at this time. Further action may be required, and LPA Cota may return to gather additional documents and conduct additional interviews. Deficiency noted and citation issued during today’s visit. Exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report and Appeal Rights was provided.