Facility Evaluation Report

On July 02, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding an incident that occurred on 06/26/2025 when the resident (R1) was administered the incorrect medication by a staff member. Upon arrival, LPA met with the Chief Operating Officer (COO), Elvyra Abare and Assistant Administrator (AAD), Beth Shirley. The LPA disclosed the purpose of the visit.

LPA interviewed three (3) staff members: S1, S2, and AAD.

The AAD stated that at around 5 pm on 6/26/2025, S1 was carrying two medication cups: one to administer to R1 and the other for another resident. While S1 administered R1’s medication, S1 sat down with the cup holding the other resident's medication on R1's bedside table. S1 then left R1’s room. S2 then went into the R1 to give R1 some juice because R1’s blood sugar was low. Once in the room, S2 saw the cup with the other resident's medication in it and administered it to R1 in error, thinking it was R1’s medication. AAD stated that on 07/01/2025, both S1 and S2 had completed re-training on Relias for medication administration.

LPA interviewed S1 over the phone. S1 stated that they administered the wrong medication to R1. S1 stated that R1’s blood sugar was low, and they went to fetch the orange juice to raise the blood sugar. S1 informed S2 that they need assistance in giving juice and medication to R1. S1 left the room and by the time they realized the mistake, S2 had already administered the wrong medication to R1. S1 stated they contacted R1’s family member and PCP at Kaiser. The Kaiser nurse followed their protocols and advised S1 to monitor R1 for any adverse effects and change in condition, and PCP would contact if they had any questions. S1 stated R1 didn’t have any side effects or adverse reaction due to the wrong medication.