Incident investigation·April 4, 2024

On 4/4/2024, Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced Case Management visit today at the facility. The department received two incident reports dated 3/28/2024 for a medication error for (R1) and 4/2/2024 for an unwitnessed fall for (R2). LPA toured the facility and interviewed the Administrator about the events related to the medication error and the resident's fall. The LPA reviewed resident records, staff records and staff training records. Medications and medication procedures were also reviewed. Both incident have been investigated by the department. The department confirmed that the facility has addressed these issues with an in-service training for Med-techs and has been actively working on the service plan for R2 since 9/29/2023. R2 was taken by the family to urgent care for a rash on 3/24/2024. R2 was diagnosed with Shingles and given two medications on that date. Both incidents were self reported by the facility. Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were cited during this visit. Advisories were given. Exit interview held and appeal rights given.