complaint·April 3, 2025

Interviews with residents revealed 2 out of 7 residents interview stated to have been given the wrong medication and 1 out of the 2 had to go to the hospital for an evaluation. 5 out of 7 residents stated to not have had medication errors. However, 1 out of the 7 stated to have not have medication available for over a week. Interviews conducted with staff revealed S1 had made a mistake by providing R1 the medication of another resident. Per S1 the other resident realized it was not their medication and let S1 know. It was then when S1 communicated with Wellness Director and they follow up with physician and responsible party, who advice R1 be taken to the hospital. Per Administrator, S1 received a corrective action and an in-service training was provided to the medication technicians on 3/27/25. Per documents reviewed R1’s medical assessment dated:4/14/24 notes, R1 is able to manage own medications. Needs and care plan dated: 4/2/25 notes R1 requires assistance with medication, and medication is provided by the medication technician. Medication error was not noted on the medication sheet. However, on 4/2/25 facility staff submitted an incident report in which it was reported that on 3/27/25 S1 provided R1 with the wrong medication and R1 was send out to the hospital. Per R1’s hospital discharge, R1 was seen for a medication problem. S1 was provided initial medication training on December of 2024, and training was retaken on 3/28/25 and 4/3/25. In-Service training was provided by wellness director on 3/27/25 to all medication technicians. Medication review revealed 3 out of 5 residents were missing at least one of their routine medication. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Stephanie Funderburg and a copy of this report, LIC 9099D, and appeal rights were provided.