Incident investigation·July 1, 2025

On July 1, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit in relation to an incident that occurred on 6/22/25. LPA met with Health and Wellness Director, Carmen Bodnar and explained the purpose of the visit. On 6/22/25, the Licensee reported that registry LVN/Med-tech administered an incorrect dose of Lacosamide medication to Resident 1 (R1) during the AM shift. R1 was supposed to receive 100mg of Lacosamide, however 150mg of Lacosamide was given. During the visit, LPA reviewed R1's file, including but not limited to; physician's orders for medication, medication list, medication administration record (MAR), and R1's medication bottles. Based on R1's medication list, R1 is required to take 1 tablet of Lacosomide (100mg) medication daily at 8am, however the med-tech administered 150mg. The facility failed to provide R1's medication as prescribed by the physician. According to the Health and Wellness Director, registry med-techs are always trained prior to administering medications for residents. In addition, it was reported that during each shift, med-techs are required to count all residents' medications. On 6/26/25, the Licensee reported that registry med-tech, provided R1 one tablet (100mg) of Gabapentin at night at 8pm, however Resident 2 (R2) noticed and reported that R1 is supposed to receive three tablets of Gabapentin instead. The med-tech then provided R1 with two more tablets. (Continue to 809C) During the visit, LPA reviewed R1's file, including but not limited to; physician's orders for medication, medication list, medication administration record (MAR), and R1's medication bottles. Based on R1's medication list, R1 is required to take 1 tablet of Gabapentin (100mg) at 9am, two tablets of Gabapentin at 1pm and three tablets of Gabapentin at 8pm. Although this incident was caught by R2 and fixed by the med-tech, the med-tech would have administered one tablet of Gabapentin to R1 at 8pm if R2 did not catch this. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. A civil penalty of $250.00 is issued today for a repeat violation within the last 12 months. Report is reviewed with the Health and Wellness Director and administrator and a copy is provided with appeal rights.