Incident investigation·February 22, 2024

Licensing Program Analyst (LPA) Renee Cambell conducted an unannounced Case Management visit on this date and met with Administrator Tony Montellano and Health and Wellness Director Anneka Ogundipe. Upon entry, LPA Campbell was greeted by the facility receptionist and observed staff cleaning the entry and dining room. Over the course of the visit, LPA Campbell observed residents eating meals, socializing with other residents, and receiving staff assistance entering or exiting the dining room. Residents were observed eating peas and carrots, Sheppards Pie, Broccoli soup and rolls with iced tea or water. Staff were later seen clearing tables or passing out dessert at resident’s request. The Department received an incident report (IR) on 02/21/24 regarding a 02/06/24 med error. During the visit, the LPA met with Health and Wellness Director Anneka Ogundipe to conduct a short interview and collect any associated documents. LPA Campbell observed an eMAR with the doctors orders to change the frequency of a prescription as well as the IR for the event dated 02/06/24. According to the orders, the start date for the medication (02/07/24) occurred after the date of the incident report on 02/06/24 as shown on the IR. The Wellness Director, confirmed that the date entered on the IR was in error. The incident instead occurred on 02/07/24 . Also, the incident report was received on 02/20/24 and was therefore received 6 days past the reporting requirement of 7 days. The MedTech (S2) who had dispensed the medication incorrectly, reported that they were at fault because they had not read the med orders or followed the dispensing procedures to avoid med errors. Per California Code of Regulations (CCR) – a deficiency is being cited on the attached LIC 809-D. Appeal Rights provided. Failure to correct deficiencies may result in civil penalties. Exit interview held and copy of report given to Health and Wellness Director Anneka Ogundipe .