complaint·July 22, 2025

(Continued from LIC 9099) On July 13, 2025 at 5:40pm a nurse from an outside agency was dispensing medication and was preparing the meds on the Med Cart. Staff #1 (S1) offered to assist the nurse and grabbed the prepared meds for Resident #1 (R1) and gave them to Resident #2 (R2). S1 immediately realized the mistake and staff informed AD Gill, the Vice President of Clinical Services, who is a Nurse Practitioner, and the community's Medical Director. The Responsible Party (RP) was also contacted. S1 is not trained to dispense medications and is not a nurse; nor a Medication Technician (Med Tech). The allegation that staff mismanaged residents' medication is Substantiated. LPA interviewed Residents #1 and Resident #2 while conducting a health and safety check. LPA also interviewed one witness and five of five staff members regarding the incident on the evening of July 13, 2025. Upon interviews with staff, R2 was closely monitored throughout the night and vitals were taken three times. S1 also remained by R2's bed until midnight. The Nurse Practitioner also visited resident the next morning and there were no adverse effects and resident remained stable, alert and at baseline. An Unusual Incident Report was also faxed to the Regional Office on July 14, 2025. Based on LPA's record review, observations and interviews, the preponderance of evidence standard has been met, therefore the allegation that staff mismanaged residents' medication is Substantiated. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Ashiman Gill, Administrator and a copy of this report was given to the facility along with a copy of the Confidential Names LIC 811,LIC 9099-D and Appeal Rights.