Complaint Investigation Report

in which Resident R1 was administered medication by a nurse after mistakenly being identified as Resident R2.

Stated that R1's identify was not verified and was thus given R2's medication.

Afterwards staff reviewed the medications that were administered to R1 and they were not serious medications in being stomach medications and that R1 would have to wait a number of hours to take the medications that are always prescribed to R1.

Staff S1 confirmed that there was a mismanagement of R1's medication and that it was corrected the same evening.

Staff S2 stated that there was a mix up in which Resident R1 was given in error Resident R2's medication.

Staff S3 stated that she had mistakenly mixed up Resident R1 and R2 and that R1 by error was given R2's Medication.

Administrator revealed that the staff did communicate that R1 was given R2's medication, but R1 was given the correct meds the same evening.

Interview with R1 who stated that there was 1 time that they administered medication incorrectly and had given him R2's medication by mistake. Stated he did get his prescribed medication shortly thereafter.

Interviews were conducted with Resident's R2- R15 who stated that they had received their medication and that they were never given incorrect medication belonging to another resident.

Document Narrative Charting lists 12/17/25 notes regarding a medication error involving R1 mistakenly being administered medication that was prescribed to R2.

Based on records reviewed and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. Deficiencies are being cited according to California Code of Regulations, Title 22.