Incident investigation·October 2, 2024

On 10/02/24, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 09/19/24. LPA met with Administrator, Stephen Macdonald and explained reason for visit. Special Incident Report (LIC 624) submitted by facility on 09/20/24 to CCL stated that R1 was send to hospital on 09/19/24 around 6PM, after R1 was given wrong medications by staff. Incident report indicated that R1 was given medications, Calcium Citrate 250mg- 2 tablets, Simvastatin 20mg-1 tablet and Memantine 10 mg- 1 tablet which were NOT prescribed by R1s physician during evening med pass on 09/19/24 around 6PM. Staff notified immediately facility’s management regarding the medication error and facility send out R1 to hospital to seek medical care. R1 came back to the facility on 09/23/24. Facility notified R1s physician and responsible party on 09/19/24 regarding medication error. LPA was notified by administrator that facility took appropriate action with staff regarding this incident per facility policy who was associated with this incident . Based on incident report, staff interviews and medication record review from the facility, R1 was given medications, Calcium Citrate 250mg- 2 tablets, Simvastatin 20mg-1 tablet and Memantine 10 mg- 1 tablet by mistake. It was determined that facility administered wrong medications to R1 which poses a immediate heath and safety risks to residents in care. Deficiencies are cited on LIC809D, pursuant to California Code of Regulations, Title 22, Section 80075(b)(5)(B) and documented on the attached LIC809D. Civil penalties may be assessed if facility does not comply with POC requirements which were issued today. The report was reviewed, appeal rights and a copy of this report was left at the facility.