Incident investigation·July 17, 2025

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to conduct a Case Management visit. LPA was greeted by concierge. Tristan Amari, Business Office Manager arrived later. On 7/10/25 CCL received an Incident Report indicating that facility had experienced a medication error for seven [7] residents on Monday, 7/7/25 ( deficiency cited, see 809D ). Later the same day, CCL received another Incident Report indicating a resident (R8) may have also received the wrong medication on 7/7/25. LPA interviewed Health and Wellness Director (HWD) Jody Livingston and Health Services Assistant (HSA) Pam Brown about medication errors that occurred on 7/7/25. Per HWD and HSA, the medications errors occurred due to Med Techs pre-pouring medication. As pertains to this incident there were two instances of pre-pouring ( deficiency cited, see 809D ). On the morning of 7/6/25, staff (S1) pre-poured medications to be administered on the morning of 7/7/25. On the evening of 7/6/25, staff (S2) pre-poured medications to be administered the evening of 7/7/25. The two [2] boxes of pre-poured medications were then placed in the medication closet, to be administered the next day. On the morning of 7/7/25, staff (S3) mistakenly pulled the evening medication box and administered evening medications to residents R1, R2, R3, R4, R5, R6, and R7. Later in the morning of 7/7/25, HSA was notified that resident R8 was not given her medications at all that morning. HSA then went to R8's room and administered their morning medications. So, R8 did receive her morning medications on the morning of 7/7/25; thereby receiving them at approximately 10:30am instead of at 8:00am as scheduled. Continued on 809C... Continued from 809C... Per incident report and submission of proof of notification to LPA, HWD notified each respective residents' primary care physician, via fax of respective residents' medication error. HWD notified respective residents' responsible parties via telephone. LPA advised going forward, facility to ensure responsible parties are notified in writing in addition to via telephone. Per HWD and HSA, pre-pouring as been an on-going issue with facility Med Techs. HWD knows that regulation states that each resident's medication shall be stored in its originally received container and no medications shall be transferred between containers. HWD advised LPA they stress to staff not to pre-pour medications, but that some Med Techs report pre-pouring to be much easier than live pouring. HWD advised LPA that S3 is currently on suspension and will be terminated. HWD advised LPA that additional Relias training will be conducted with all direct care staff that administer medication. In order to stress the importance of live pouring, HWD and HSA will formulate a Med Tech test based on training requirements specified in Health and Safety Code (HSC)1569.69(a)(5) for all Med Techs. HWD will send copy of prospective test to CCL before administering test to ensure compliance with HSC. Additionally, HWD and HSA have scheduled a staff meeting to address pre-pouring. HWD will address the pre-pouring by eliminating the medication boxes in which the medications are pre-poured, thereby eliminating the ability to pre-pour. Per HSA, HSA will be auditing medication room closet and medication cart to see if they find any pre-pouring. The audit will occur daily and randomly anywhere between 9:00am and 5:30pm, which covers both shifts on which medications are administered. If HSA finds instances of pre-pouring, identified staff will immediately be given a write up that is last and final. Additionally, identified staff would face discipline up to and including termination. HWD advised LPA, facility is going to re-educate staff on the logistics of giving medications, such as reviewing proper medication cart placement and procedures. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with BOM. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with BOM and a copy of this report was given .