Health inspection·January 8, 2026

The facility must ensure that it's §483.45(f)(2) Residents are free of any significant medication errors. §72313. Nursing Service--Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. (7) Patients shall be identified prior to administration of a drug or treatment. §72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 10/22/2025, the California Department of Public Health (CDPH) received a complaint alleging a staff member administered the wrong medications to a resident (Resident 1) on 10/22/2025. Resident 1's blood pressure dropped, paramedics were called and Resident 1 was transferred to a General Acute Care Hospital (GACH). On 10/23/2025, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. During the investigation, CDPH determined Resident 1 received Resident 2's scheduled 9 am medications in error on 10/22/2025. The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 1 provided direct supervision to Student Nurse (SN) 1 on 10/22/2025 when administering scheduled 9 am medications to Resident 1. 2. Ensure the five rights of medication administration were followed; the right resident, the right medication, the right dosage, the right time and the right method (route) prior to administering medications to Resident 1. 3. Ensure they followed their Policy and Procedure (P/P), titled, "Administering Medications" revised 4/2019, that indicated, "the individual administering medications verifies the resident's identity before giving the resident his or her medications, methods of identifying the resident include, checking the identification band, checking photograph attached to medical record and if necessary verifying resident identification with facility personnel, the individual administering the medication checks the label three times to verify the right resident, the right medication, right dosage, right time and right method (route) of administration before giving the medication. These deficient practices resulted in Resident 1 receiving valsartan (a medication that lowers the blood pressure), multivitamin with minerals, Guaifenesin (a medication that helps loosen and thin mucus in the throat and chest) extended release ([ER] version of pill where medicine steadily throughout the day in the body), Eliquis (a medication used to prevent blood lots, thin blood), Carvedilol (used to lower the blood pressure and heart rate), Keppra (a medication used to treat seizures), Magnesium Oxide (a mineral supplement which could cause diarrhea, bloating and stomach cramps) in error. This deficient practice resulted in Resident 1 not receiving his prescribed medications such as Glipizide (a medication used to treat type 2 diabetes [DM] a disorder characterized by difficulty in blood sugar (b/s) control and poor wound healing), Metformin (a medication used to treat high b/s), Baclofen (a medication used to treat tightness and stiffness caused by muscle spasms), vitamin D, Iron, Finasteride (a medication used to treat an enlarged prostate [male organ]) and Lacosamide (a medication used to treat seizures). Resident 1 was subsequently transported to a GACH due to a low blood pressure reading of 96/65 mmHg and for monitoring and evaluation of the risk of bleeding, alterations in b/s, and allergic reactions as a result of receiving the above medications in error. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on 4/23/2024 and readmitted on 8/10/2025 with diagnoses including hemiplegia and hemiparesis affecting the resident's right side, atrial fibrillation (a-fib) and type 2 DM. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 8/14/2025, indicated Resident 1 had moderate cognitive impairment with the ability to understand and be understood by others. A review of Resident 1's Change of Condition (COC) document, dated 10/22/2025, indicated Resident 1 received the wrong medication. A review of Resident 1's Order Summary Report (Physician's Order), dated 10/22/2025, indicated to transfer Resident 1 to a GACH Emergency Room (ER) for further evaluation related to the wrong medication administration. A review of Resident 1's Nurses Progress Notes, dated 10/22/2025, indicated Resident 1 was transferred to a GACH via 911 for evaluation. A review of the GACH's ER records dated 10/22/2025, indicated Resident 1 was admitted to the GACH on 10/22/2025 and presented to the ER for evaluation due to receiving the wrong medications at the skilled nursing facility (SNF) where Resident 1 resided. The ER records indicated Resident 1 underwent blood tests and radiological studies to rule out the risk of bleeding and other adverse drug effects. A review of the facility's Cell Phone Log, dated 10/22/2025, indicated the following text messages between LVN 1 and Resident 1's physician: 1. At 9:52 a.m. - a text message was sent to Resident 1's physician indicating Resident 1 received the wrong medications. 2. At 9:56 a.m. - a text message from Resident 1's physician indicating "type it out please, what was the medication error?" 3. At 9:58 a.m. - a text message from LVN 1 indicating, "Resident 1 received medications that were for another resident (Resident 2). I am trying to send a list of medications, but the internet went down, I am unable to send his list of medications to compare to the ones he received." 4. At 10:27 a.m. - a text message Resident 1's physician indicating to "monitor blood pressure for 72 hours, bleeding precautions for 10 days, let the Director of Nursing (DON) and Administrator (ADM) know of the medication error which can be fatal, needs to be logged via appropriate channels, do not let it happen again, I cannot see pictures, type out medication names and dosing please." 5. At 11:27 a.m. - a text message was sent to Resident 1's physician indicating Resident 1 received the following medications: "Valsartan 40 mg, Multivitamin with minerals, Guaifenesin ER 600 mg, Eliquis 5 mg, Carvedilol 6.25 mg, Keppra 250 mg, Mag Ox 400 mg." 6. At 11:30 a.m. - a text message sent to Resident 1's physician indicating Resident 1's prescribed medications were held; Glipizide 5 mg, Metformin 100 mg, Baclofen 10 mg, Vitamin D, Iron, Finasteride 5 mg and Lacosamide 50 mg. 7. At 2:01 p.m. - a text message sent to Resident 1's Physician indicating "can we send him (Resident 1) to the ER for evaluation, I am very concerned?" blood pressure 96/65, Resident 1 has been sleeping (more) than usual. 8. At 2:15 p.m. - a text message from Resident 1's physician indicated "who, we need names." 9. At 2:16 p.m. - a text message sent to Resident 1's physician indicated Resident 1 "received the wrong meds." 10. At 2:16 p.m. - a text message from Resident 1's physician indicated, send Resident 1 to the GACH. During an interview on 10/23/2025, at 8:45 a.m., Resident 1 stated on 10/22/2025 he was transported to a GACH because he received the wrong medication. Resident 1 stated yesterday morning (10/22/2025), he was given medication by a new nurse (SN 1). Resident 1 stated SN 1 did not ask what his name was, his date of birth nor did she review his medications with him prior to administering them to him. Resident 1 stated he did not remember much of yesterday, his wife was the one that noticed something was wrong him. During a telephone interview on 10/23/2025, at 10:30 a.m., Resident 1 's Responsible Party (RP) stated on 10/22/2025 she noticed that Resident 1 was sleepier than usual. The RP stated she asked Certified Nurse Assistant (CNA) 1 to take Resident 1's blood pressure and his blood pressure results were in the 80's or low 90's. The RP stated she was concerned because Resident 1 was so sleepy that he would not drink his water and he could not remember if he slept well the night before, which was unusual for him. The RP stated the DON entered Resident 1's room around 1 p.m. to assess Resident 1 and that was when she (RP) was first notified that Resident 1 had received the wrong medication that morning. During an interview on 10/23/2025, at 1:30 p.m., the DON stated on 10/22/2025 at approximately 10 a.m., LVN 1 informed him that she was mentoring SN 1 when SN 1 gave Resident 1 the wrong medication. The DON stated LVN 1 reported that Resident 1 received Resident 2's scheduled 9 a.m., medications in error. The DON stated he assessed Resident 1 at approximately 1:30 p.m. and found Resident 1 was sleepy but arousable with his BP was in the 90s. The DON stated he informed the RP that Resident 1 received several medications in error and the RP insisted that he call 911 to transport Resident 1 to the GACH. The DON stated when EMS arrived to the facility he provided them with a list of medications that Resident 1 received in error. During a telephone interview on 10/23/2025, at 2:18 p.m., SN 1 stated he was allowed to administer medications under the direct supervision of a licensed nurse and on 10/22/2025 he was assigned to shadow LVN 1 during a medication pass. SN 1 stated during the morning of 10/22/2025 he was standing at the medication cart which was located in the doorway of Resident 1 and Resident 2's shared room. SN 1 stated LVN 1 put several medications in a cup then handed him the cup that had multiple tablets in it. SN 1 stated he was instructed by LVN 1 to give "B bed" (Resident 1) all the medications that were in the cup, two at a time with a spoon and water. SN 1 stated he went to Resident 1 and proceeded to administer the medications that were in the cup to Resident 1 without LVN 1 present to watch him. SN 1 stated he did not identify Resident 1 by asking his name or verifying Resident 1's identity by picture. SN 1 stated after administering medications to Resident 1, he left the room, about 20 minutes later he returned to the medication cart and LVN 1 handed him another cup with medications in it that were crushed and mixed in applesauce and instructed him to give the medications that were in the cup to the resident in bed "B." SN 1 stated he asked LVN 1 to clarify who he was to administer the medications to and LVN 1 repeated again the resident in bed "B." SN 1 stated he informed LVN 1 that he had already given medications to the resident in bed "B" per her (LVN 1's) instructions. SN 1 stated that was when LVN 1 informed him that he had administered Resident 2's medications to Resident 1 in error. SN 1 stated LVN 1 notified the DON and Resident 1's physician of the medication error. SN 1 stated he did not follow his school policy nor the facility's policy and placed Resident 1 at risk for harm. During a telephone interview on 10/24/2025, at 1:55 p.m., SN 2 stated on 10/22/2025, she was assigned to shadow LVN 1 during a medication pass. SN 2 stated LVN 1 often remained in the doorway near the medication cart and did not accompany her (SN 2) to the resident's bedside while she administered medications to the residents. SN 2 stated LVN 1 refers to residents by their bed assignment (e.g., "A" or "B" bed), which she found confusing, and she (LVN 1) would often prepare medications for another resident while she talked to staff or other residents who were at the medication cart. SN 2 stated she should not have administered medications to any residents without direct supervision from a licensed nurse. During a telephone interview on 10/24/2025, at 2:37 p.m., LVN 1 stated on 10/22/2025 she was assigned to mentor three nursing students. LVN 1 stated at approximately 9 a.m., she prepared medications with SN 1 to administer to Resident 2 and handed the medications that were in a medication cup to SN 1. LVN 1 stated she was standing at the medication cart in the doorway of Resident 1 and Resident 2's shared room and planned to watch SN 1 administer the medication to Resident 2 but turned her back to SN 1 to start preparing Resident 1's medications with SN 2. LVN 1 stated when SN 1 returned to the medication cart she informed SN 1 that they would administer Resident 1's medications which she had already crushed and placed in apple sauce in a medication cup. LVN 1 stated SN 1 informed her that he had already given Resident 1 his medication and that was when she realized SN 1 had administered Resident 2's medication in error to Resident 1. LVN 1 stated she notified the DON and Resident 1's physician of the medication error. LVN 1 stated her not supervising SN 1 during a medication pass, placed Resident 1 at risk for adverse effects and harm. During an interview on 10/24/2025, at 4:17 p.m., the DON stated all licensed nurses in the facility were trained on how to mentor nursing students. The DON stated, per the agreement with the Nursing School, students could administer medications to the residents under the direct supervision of a licensed nurse. The DON stated LVN 1 should have accompanied SN 1 to the resident's bedside during the medication pass to ensure the medications were properly administered by utilizing the five rights of medication administration: the right resident, right medication, right route, right time, and right dose. The DON stated licensed nurses should not hand medication they prepare for administration to anyone and allow them to administer the medication to a resident out of their presence and they should observe the complete administration of the medication before leaving the resident. The DON stated the failure of LVN 1 to follow the correct medication administration steps led to Resident 1 receiving the wrong medications and placed Resident 1 at risk for adverse reactions which led to Resident 1's COC and transfer to a GACH for evaluation and treatment. During a telephone interview on 10/27/2025 at 9:36 a.m., the facility's Consultant Pharmacist (CP) stated that five rights of medication administration (right patient, right med, right time, right dose, right route) should be followed when administering medications to residents. The CP stated prior to medication administration the LVN must ensure the identity of the resident by using at least two (2) identifiers, such as: name, picture, wrist ID band, to make sure medications to be administered were for the right resident. The CP stated LVN 1 failed to follow 5 rights of medication administration and failed to follow facility medication administration guidelines, by failing to ensure the right medications were administered to the right resident. The CP stated these were considered significant medication errors. The CP stated LVN 1 failed to supervise the student during Resident 1's medication pass and this caused harm to Resident. A review of the facility's Job Description titled, "Licensed Practical/Vocational Nurse" revised 5/2022, indicated general duties and responsibilities included the following: provides nursing services to residents in accordance with scope of practice, facility policies, and professional standards of care..... A review of the facility's P/P titled, "Administering Medications" revised 4/2019, indicated.......the individual administering medications verifies the resident's identity before giving the resident his or her medications, methods of identifying the resident include , checking the identification band, checking photograph attached to medical record and if necessary verifying resident identification with facility personnel, the individual administering the medication checks the label three times to verify the right resident, the right medication, right dosage, right time and right method (route) of administration before giving the medication. A review of the Nursing School's updated "Clinical Objective Guidelines/Contract" with the SNF, indicated the students perform procedures according to the facility's policy manual, perform medication administration safely under supervision, including correct dosage calculation and the right of medication administration. The facility failed to 1. Ensure LVN 1 provided direct supervision to SN 1 on 10/22/2025 when administering s