Follow-up on corrections·December 10, 2024

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct a case management visit. LPAs Moleski and Williams met with director James Dial and explained the purpose of the visit. LPA Moleski reviewed an incident report that was sent to the Community Care Licensing Division (CCLD) on 12/4/24. The incident report described a medication error which was discovered on 11/27/24 by a medication technician (S1). S1 had attempted to get a refill for a resident's (R1's) thyroid medication on that date, but was told that the medication was not able to be refilled, as there should be doses remaining, according to the incident report. The incident report stated that there was only one pill of the medication remaining at that time. In an interview, S1 said the medication, given in the correct dosage, should have lasted through 12/26/24. In an interview, the facility's health services director (S2) said that both night shift medication technicians (S3 and S4) had been giving one full pill of the medication, rather than the half pill prescribed. S2 said that they asked both S3 and S4 separately what they had been giving R1, and they both reported that they were giving one full pill. This had occurred on multiple occasions, according to the incident report. Neither S3 nor S4 were present at the facility during this visit. LPA Moleski reached out via telephone to each but did not receive a response during this visit. This facility is hereby cited per 22 CCR Section 87465(a)(4). An exit interview was held with Dial. Appeal rights and a copy of this report were left with Dial.