On 6/5/26 CCL received an Incident Report indicating a medication error for resident (R1). Report indicates that on 5/30/26, at approximately 9:00pm Admin was notified that staff (S1) had signed for Nystatin powder that was not administered to R1. Upon facility investigation, it was determined that R1 missed one 5:00pm dose. Facility terminated S1 on 6/8/26 for falsifying documentation.

On 6/16/26 CCL received an Incident Report indicating a medication error for resident (R2). Report indicates that on 6/15/26 Administrator was notified that staff (S2) had administered a dose of Claritin D that is prescribed to be given only once every 24 hours. S2 administered the second dose without verifying the time the previous dose had been administered. R2 was subsequently seen by their physician. Resident was monitored for adverse reactions. No adverse reactions observed. Facility has conducted medication training with staff with an emphasis on reviewing MARs, medication instructions, dosage requirements, and administration procedures. Additionally, Administrator will conduct periodic audits of medication records. S2 will be receiving final written today and a Counseling and Corrective Action (CCA). Admin showed LPA paperwork for corrective action.

On 6/17/26 CCL received an Incident Report indicating a medication error for resident (R3). Report indicates that on 6/16/26 facility Administrator was notified by staff that staff (S3) administered two (2) medications prescribed for hypertension. However, R3's blood pressure was reading was outside the administration parameters specified on doctor's orders. Additionally, S3 did not report their error to the Administrator. Upon learning of the error, Administrator immediately contacted nurse consultant for guidance and requested a

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• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

LPA discussed with Administrator the seriousness of these medication errors and actions taken and/or in need of being taken to ensure residents do not experience medication errors. So many errors in such a short period of time indicate a need for a better structure for medication management. LPA and Administrator discussed the times and places at which medications are administered. Perhaps changing the structure of how and when medications are administered will help to eliminate any distractions or confusion for the staff doing the administering. Admin advised LPA that she has already analyzed the medication administration procedure and has begun implementing changes with staff.

A civil penalty in the amount of $250 is being assessed today for repeat violations within a 12 month period (see LICF21)

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.