Incident investigation·January 23, 2023

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management due to receiving an incident report. LPA met with facility staff and explained the purpose of the visit. LPA was later met by Administrator Leonil Nunez. Facility staff Lionel Nunez self reported an incident that occurred with a resident on 12/27/2022. On 12/27/22, Resident 1 (R1) mistakenly took another resident's medication. "Staff reported that after [S1] initially administered [R1's] AM medications ... Staff then began to prep for another resident’s medication administration at the homes medication prep area.  During staff’s preparation of the other residents medication, 1 pill for the resident bubble pack was put into a pill cup. As staff turned to get the residents other pill bubble pack, [R1] walked by and noticed the single pill in the cup, and proceeded to take it.  When staff noticed this error, [S1] immediately asked [R1] why [R1] took the medication, [R1]replied, “I took it because it was my Multi-Vitamin pill.”  Staff immediately called the administrator and instructed staff to call 911. Resident was taken to the emergency room for observations. Resident was then later admitted for other health related issues. According to the administrator, the resident is currently doing well and has returned to the facility. LPA interviewed Administrator Leonil and facility staff regarding policies and procedures. Administrator stated a training was conducted with all staff. The training focused on medication administration and was led by a Registered Nurse. Per California Code of Regulations (CCR), Title 22, deficiencies were cited due to the above information. Appeal rights were provided. An exit interview was held with Leonil, and a report was provided.