complaint·April 15, 2025

Review of facility records revealed that facility staff had self-reported this medication error for R1 to the department on April 2, 2024. The records reviewed stated that on April 1, 2025, R1 was administered another resident’s medication mistakenly during a routine medication pass. Review of R1’s medical assessment dated October 24, 2024, revealed that R1 is able to communicate their needs and unable to administer and store their own prescription and PRN medications. Review of R1’s medication log revealed that R1 was not prescribed the two medications they were administered and ingested on April 1, 2025. Interviews with staff, residents, and outside sources all corroborated that R1 has been administered another resident’s medication. R1 did not have any adverse reactions besides a slight decrease in blood pressure but returned to their baseline blood pressure the following day. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of evidence exists to support the allegation. One deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Resident Services Director , to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.