Facility Evaluation Report

Licensing Program Analyst Leibert arrived unannounced for the purpose of following up on 2 incident reports involving medication errors. LPA met with the Administrator and discussed the incidents. On July 22, 2024, two residents, R1 and R2, missed their scheduled pm injections and on July 23, 2024, R1 missed a AM injection. The error was discovered on 7/23/24 and it was determined that the nurse scheduled to work the shift did not come to work and med techs on duty did not know that management was not made aware of the issue when it occurred. As a Result, all 17 staff who dispense medications were given additional training by Omnicare Pharmacy on August 01, 2024. R1 and R2 were given additional wellness checks and suffered no apparent difficulties. All required notifications were made.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.