Incident investigation·July 2, 2025

On July 02, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding an incident that occurred on 06/26/2025 when the resident (R1) was administered the incorrect medication by a staff member. Upon arrival, LPA met with the Chief Operating Officer (COO), Elvyra Abare and Assistant Administrator (AAD), Beth Shirley. The LPA disclosed the purpose of the visit. LPA interviewed three (3) staff members: S1, S2, and AAD. The AAD stated that at around 5 pm on 6/26/2025, S1 was carrying two medication cups: one to administer to R1 and the other for another resident. While S1 administered R1’s medication, S1 sat down with the cup holding the other resident's medication on R1's bedside table. S1 then left R1’s room. S2 then went into the R1 to give R1 some juice because R1’s blood sugar was low. Once in the room, S2 saw the cup with the other resident's medication in it and administered it to R1 in error, thinking it was R1’s medication. AAD stated that on 07/01/2025, both S1 and S2 had completed re-training on Relias for medication administration. LPA interviewed S1 over the phone. S1 stated that they administered the wrong medication to R1. S1 stated that R1’s blood sugar was low, and they went to fetch the orange juice to raise the blood sugar. S1 informed S2 that they need assistance in giving juice and medication to R1. S1 left the room and by the time they realized the mistake, S2 had already administered the wrong medication to R1. S1 stated they contacted R1’s family member and PCP at Kaiser. The Kaiser nurse followed their protocols and advised S1 to monitor R1 for any adverse effects and change in condition, and PCP would contact if they had any questions. S1 stated R1 didn’t have any side effects or adverse reaction due to the wrong medication. Continued on LIC809-C LPA interviewed S2 over the phone. S2 stated that S1 mentioned that R1’s blood sugar was low and asked S2 to fetch orange juice for R1. S1 further asked S2 to give R1 their medications that were left on R1’s bedside. S2 gave the juice and the medication to R1 assuming the medication was for R1. S2 stated that S1 reached out to R1’s PCP and family about the medication error. LPA reviewed R1’s progress notes for 06/26/2025, which documented the medication error. The notes indicated R1's vital readings and the exchange with the Kaiser nurse and R1’s family member. LPA visited R'1 room to interview R1, but R1 was observed to be sleeping at that time. The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, and Plans of Correction were reviewed and developed with the Assistant Administrator. A copy of this report and appeal rights were discussed and provided to the Assistant Administrator, Beth Shirley, whose signature on this form confirms receipt of these documents.