Incident investigation·November 19, 2025

On 11/19/2025, Licensing Program Program Analyst(LPA) John Calandra arrived at the facility to conduct a Case Management visit in regards to an incident in which a resident, R1 was given multiple doses of a medication. LPA Calandra was greeted by Alex Tayebi, Executive Director and explained the purpose of the visit. On 11/17/2025, the Department received an incident report describing a medication error incident that occurred on 11/15/2025. Based on the report, R1 received extra doses of a medication over a two day period. During the visit on 11/19/2025, LPA learned that R1 was recently discharged from the hospital for another infliction and was provided the medication at the hospital in the morning prior to discharge. Based on record review, hospital discharge paperwork does not reflect the change in medication administration post discharge. Based on interview, R1 is feeling well and no side effects have been reported. LPA received the following documents while at the facility: Pharmacy medication orders, hospital discharge documentation, and incident reports. No deficiencies cited during today's visit. An exit interview was conducted. This report was reviewed with facility representatives and a copy provided via email.