Facility Evaluation Report

On April 16, 2025, at 11:50 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding a medication error incident that occurred on 04/06/2025 when the resident (R1) was given medications of another resident. Upon arrival, the LPA was greeted by the Director of Health Services (DHS) Layana Santos. The LPA disclosed the purpose of the visit. The Executive Director (ED) Mark Baddas joined shortly after.

LPA interviewed one (1) resident (R1) and three (3) staff members: Director of Health Services (DHS), Medication Technician (S1) and LVN Community Nurse (S2).

R1 stated they were not bothered about the medication error, but this could happen was disturbing. R1 stated they always asked what medicines were given to them and thought more training could help to prevent such errors in the future. R1 confirmed they had no adverse side effects of the wrong medications given.

S1 stated they felt the work overload caused the medication error and they were honest about the error and made sure the resident was doing ok and hence they followed the process of informing the nurse on duty. S1 stated they have been retrained on the med training on 04/09/2025.

S2 stated that S1 came to them and informed about the medication error. S2 followed the procedure by taking resident vitals, told the doctor and the family. S2 checked on R1 every hour after that to make sure there are no side effects.

DHS stated they were putting more checks in place, more frequent audits, added additional layers to make sure the med techs were properly dispensing medications. The facility followed the protocols by frequently checking R1 for change of condition, informed their doctor and the family member. DHS stated that the med tech had been given additional training to ensure that they do not make the medication error again.