Incident investigation·October 11, 2022

Licensing Program Analyst (LPA) Daniela Huerta and Interim Assistant Program Administrator (IAPA) Icela Estrada conducted an unannounced case management visit to follow up on two self-reported incident reports, received by the Regional Office on 7/07/22 and 7/20/22. LPA and IAPA identified themselves, stated the purpose of the visit, and met with Chad Coleman, Executive Director. During the visit, Pam Talamantes, Residence Services Director arrived and met with LPA and IAPA. The facility self-reported two medication errors at the facility. On 7/06/2022 Resident # 1(R1) was given medication that belonged to Resident # 2 (R2) by Staff #1. R1 was given the following medications: Aspirin 81mg, Calcium 600mg, Colace 100mg, Escitalopram 5mg, Miralax 17GM, Spironolactone 25mg, Trospium Chloride 20mg, Tylenol 325mg, Vitamin D3. There was no adverse effects due to the medication error. The Department verified that the licensee cross-reported to the Primary Care Physician (PCP) and responsible party (RP). On 7/18/2022 Staff #2 did not administer medication to 26 residents. On 7/18/2022 at around 4:00 PM, Staff #3 noticed the medication bubble packs not popped on 7/18/2022 for the day shift. Upon further investigation by Staff #4, it was discovered that Staff #2 electronically signed for medication administration for all (26) residents in the Memory Care community, however, did not pop any of the medications out of the bubble pack for that day. Staff #2 was placed on suspension that same day, and after facility concluded their internal investigation Staff #2 was terminated on 08/01/2022. The Department verified that the licensee cross-reported to the PCPs and RPs for the 26 residents. A review of records revealed the licensee had a local pharmacy provide on site training to all medication technicians on July 15 and July 27, 2022 to address both incidents. A deficiency is cited in accordance with the California Code of Regulations, Title 22, Division 6, Chapter 1, and is noted on the attached LIC802-D. An exit interview was conducted and a copy of this report and Appeals Rights (LIC 9058 01/16) were provided to Pam Talamantes, and her signature on this form, acknowledges receipt of these rights.