Incident investigation·July 16, 2025

On July 16, 2025, Licensing Program Analyst (LPA), Ivan Avila arrived at the facility unannounced to conduct a case management visit. LPA met with Laurie Schlottman and explained the purpose of the visit. The purpose of today's visit is to follow up on an Unusual Incident/Injury Report that was sent to the Department on June 24, 2025. During the incident, medication was administered to the wrong resident in care. Staff stated they got distracted and believed the medication was for R1. Staff immediately called the Administrator. The Administrator instructed staff to contact Poison Control. Instructions were given by Poison Control to take R1 to the emergency room due to a high medication dose R1 does not normally take. R1 was taken to Shasta Regional Medical Center and was later sent home with instructions for staff to monitor R1 throughout the night. LPA explained to the Administrator on the importance of ensuring that all medications are dispensed as outlined in the resident’s physician orders and as outlined in Title 22 Regulations. Administrator reported that staff that dispensed the wrong medication will be going through additional training. LPA also advised that if this medication error happens again, a citation will be issued. No deficiencies were cited during today's Case Management - Incident Inspection. Exit interview was conducted and a copy of this report was signed and given to the Administrator.