Incident investigation·July 17, 2025

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. LPA met with General Manager (GM) Billy Mitchell. The purpose of the visit was to follow-up on two incidents that was reported to the Department on 07/14/2025 and 07/17/2025. On 07/14/2025, the Department was notified of alleged abuse between resident (R1) and R1’s private caregiver. It was stated that on 07/14/2025 around 1:00am, R1 pulled his/her pull cord and when staff responded R1 reported that he/she felt dizzy because R1’s private caregiver hit him/her in the head. Staff immediately contacted 911 and assessed the resident. There were no visible injuries such as bruising, redness, scratches, or marks on R1’s skin. The police arrived and R1 did not know why the police was there. The facility reported the incident to R1’s responsible party and felt R1 wasn’t in the right state of mind. Based on interview and record review, R1 has mild cognitive impairment and history of confusion upon waking up. R1’s family continued to keep services from the same private caregiver. Staff stated the resident has shown no indications of abuse. R1's physician's report, service plan and progress notes were obtained. On 07/17/2025, the Department was notified of a medication error that occurred during the morning shift of 07/17/2025. It was reported that the MedTech in training (S1) administered resident (R2)’s medication to resident (R3). See LIC809-C for additional information. S1 was shadowing another MedTech (S2) on the floor. During the medication pass, S1 and S2 did not reconfirm the resident's medication prior to administering it. When S1 and S2 went to administer R2’s medication, the staff noticed they only had R3’s medication cup and then realized that R3 was given R2’s medication. R3 already left the community with family once the medication error was found. R3’s family and physician was immediately informed. The facility staff advised R3's authorized representative to seek medication attention, however it was stated that R3 was doing well. It was stated R3's family will monitor R3 during their outing and take action when needed. The facility plans to remove both MedTechs from the floor. Both MedTechs will be required to complete the medication training courses again prior to working on the floor. The Licensee will also provide training for the MedTech trainers regarding medication pass oversight between the trainer and trainee. The review of the facility’s compliance history showed another medication error of a similar incident occurred on 02/25/2025. The incident was reported to the Department on the same day. On 02/27/2025, LPA Kabariti followed up with the incident via phone call and it was stated that R1 was administered R2’s medication on accident by a MedTech in training (S3). S3 was shadowing MedTech (S4). S3 grabbed the wrong medication cup and did not reconfirm the medication prior to administering it to R1. R1 was taken to the hospital for monitoring and returned to the facility on the same day. Based on interview and record review, there were not adverse reactions from the medication error. After the incident, the facility removed both MedTechs from the floor and were required to complete re-training on medications. Based on record review, S4 completed the re-training on medications after the incident. Staff stated that S3 did not want to continue to pursue the MedTech position. Based on review of S1 – S4’s staff training records, S1 – S4 completed multiple training courses regarding medications. A deficiency was cited per California Code of Regulations, Title 22 regarding the medication errors. See LIC809-D. This report was reviewed with General Manager, Billy Mitchell and a copy of the report and appeal rights were provided.