complaint·October 7, 2025

(Continuation from LIC9099) S1 reported that S1 did not confirm if the clear cup matched R1’s room number and proceeded to give R1 the medication. S1 watched R1 swallowed the medication and walked out the residents room. According to S1, S1 did not notice the error until arriving to Resident #2’s (R2) unit and could not find R2’s medication. S1 called Staff #2 (S2) and informed S2 of the error. S1 was instructed to wait for S2’s guidance. Interview conducted with staff and R1 confirmed R1 was informed approximately 2 hours after the medication error. R1’s primary physician and responsible party were notified of the error. Interview with staff reported that R1’s Primary Care Physician instructed staff to monitor R1 for any side-effects. Interviews with staff and R1 confirmed R1 did not receive R1’s normal AM dosage of medication after the medication error as instructed by the Primary Care Physician. Interviews conducted with R1 and staff detailed that R1 was placed on alert charting where R1’s vitals were taken every hour. Records review conducted of the facility’s incident report confirmed the details of the incident. A records review conducted for R1’s physician report confirmed R1 requires assistance with medication management (i.e. assistance with administering medication, PRN medication, and storing medication). A records review conducted of R1’s Electronic Medication Administration Record (EMAR) confirmed that R1 did not receive their morning dosage of medication as instructed by the Primary Care Physician. Based on interviews and records review, this allegation is deemed Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Pursuant to the California Code of Regulations, Title 22, Division 6, Health and Safety Code, a deficiency is cited on the attached LIC 9099-D. An exit interview was conducted where a copy of this report was provided and discussed, along with a copy of LIC9099-D, and Appeal Rights were provided to Administrator, Jonetta Eads.