Incident investigation·August 11, 2021

Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to the facility for the purpose to follow up on an self reported Incident regarding a Medication error that was received by the department on 08/04/2021. LPA met with Director of Resident Engagement Izze Perez and Administrative Assistant Trish Arnold and discussed the purpose of the visit. LPA Tirre toured facility with Director of Resident Engagement Izze Perez. During visit LPA toured lobby, dining areas, 1st and 2nd floor resident rooms, bistro areas as well as wellness center. During visit LPA met with Director of Resident Engagement and Administrative Assistant to discuss the Incident Report involving the details in the incident regarding Medication errors for 8 residents in care. During the discussion Director of Health Services Arienne Ghammangne and Regional Vice President of Operations Tana Mcmillon also joined in conversation via speaker phone. On 8/3/21 it was reported to Director of Health Services and VP of Operations that S1 was not giving residents medications as ordered but was signing as given, upon verification, noted residents medications in the destruction cabinet. Facility initiated an investigation into incident. On 8/4/21 S1 was suspended and on 8/5/21 S1 sent in a emailed letter of resignation to Management. On 8/5/2021 approximately 8:00 AM LPA Tirre spoke with Silverado's VP of Operations Tana Mcmillion who stated at the time that facility was conducting their own investigation regarding incident S1 at the time had been suspended. VP stated that facility conducted new training regarding Personal rights at facility involving a different incident. VP had mentioned facility's previous Administrator had been let go and facility has been in process of getting a new Administrator. VP received an email from staff regarding S1.which was forwarded to LPA. VP also stated the facility contacted The Department, The residents physicians and families regarding incident. VP stated that residents were being monitored and were stable. CONTINUED ON LIC 809C DATED 8/11/21 During today's visit VP of Operations mentioned that facility had another incident regarding Medication errors on 8/10/21 regarding a Nursing student, Resident receive incorrect medication for prostate, No adverse reactions noted, resident remains stable and physician and family was contacted. Physician advised staff to continue to monitor resident. Facility informed West Coast University Instructor, students and on site nurses that Nurses/Staff will be physically present when Nursing Students are passing medications. During today's visit LPA interviewed staff, reviewed MARs, reviewed medications as well as requested documents. Based on this review, the following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was given to the facility representative at the time of the visit along with a copy of the LIC 809-D and LIC 811. The right to appeal the following citation was discussed at the time of the exit interview and a copy of the appeal rights was given.