Incident investigation·September 2, 2021

At approximately 11:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to a medication error. LPA met with Executive Director Angie Smith, reviewed records and interviewed staff. On 8/26/2021, during the PM medication pass, Staff (S1) administered the wrong medication to a resident. Notifications were made to CCLD, physician and family. An internal investigation was completed and a copy provided to LPA. S1 received additional training. Executive Director requested additional training through the pharmacy for all medication staff. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Executive Director and Appeal rights were given.