Incident investigation·July 16, 2021

On 07/16/2021 at approximately 9:44am Licensing Program Analyst (LPA) Allison O'Hollaren arrived unannounced to conduct a case management visit regarding a self-reported incident that occurred on 06/06/2021. LPA met with Administrator, Jane Bernadino and explained the purpose of the visit. During the visit LPA spoke and reviewed incident with Administrator. Administrator stated that facility was responsible for notifying hospice agency when Resident R1's medications need a refill. On 06/04/2021 the facility contacted R1's hospice agency notifying agency that R1 would need a refill of seizure medication by 06/05/2021 in the afternoon. On 06/04/2021 R1 was no longer receiving hospice services and medications had been sent to R1's medical provider. The facility then contacted R1's medical provider on 06/04/2021, but the medical provider did not have the medication order. On 06/05/2021 R1 took R1's last pill of medication in the morning and the facility did not receive the medication until 06/06/2021. On 06/06/2021 R1 had a seizure. The following deficiency was cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.