Incident investigation·January 23, 2023

Licensing Program Analyst (LPA), Jill Nakagawa arrived unannounced at Atria Covell Gardens on 01/23/2022 for the purpose of following-up on an incident report that was self-reported to the CCL Regional Office (RO). LPA was screened following Covid-19 protocols and was granted access into the facility and was met by Administrator, Kawana Anthony. CCL received an incident report reporting a medication error. The error occurred on 01/17/2023. While S1 was dispensing medication, R1 was given the prescribed medication for another resident. R1's responsible party and prescribing doctor were notified of medication error and R1 was taken to hospital for evaluation. R1 returned to facility with no adverse reactions or change in condition. Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights were given.