Follow-up on corrections·June 15, 2023

Licensing Program Analyst (LPA), Shannan Hansen arrived unannounced at Aegis Living Corte Madera for the purpose of following-up on an incident report that was forwarded to the Regional Office (RO). LPA met with Administrator Donald Stamets. CCL received a self reported incident report from facility reporting 13 medication errors. The errors occurred on the evening of 06/07/2022 while medication care manager (S1) was dispensing medication. R1-R13 were not given prescribed evening medications during medication passing as prescribed by physicians. S1 passed all other medications for the evening to assisted living residents and neglected to finish. Medication error was discovered by Dir. Of Operations in AM report on 6/8/2023 at 8:00am and reported to nursing to conduct 72 hr alert charting and monitor for adverse effects for R1-R13. Responsible parties and prescribing doctors were notified of medication error. Medication trainings have been conducted and will continue. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..