Incident investigation·September 9, 2024

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to follow up on an incident reported to our agency on July 29, 2024. LPA was greeted and granted entry into the facility by Ashiman Gill, Administrator (AD) at 10:30am and explained the reason for the visit. The purpose of today's visit is to follow-up on a self reported incident report received by our Duty Line on July 29, 2024 by Libbie Retts, RN, MSN, CENP, Director of Health Services (DHS). A medication error was reported that Resident #1 (R1) did not receive some medications for three days and medications were discovered by a staff member; who reported to the DHS. DHS immediately contacted physician and responsible party and investigated the incident with staff. Resident was monitored and did not have any effects from not taking the missing medications. Staff in-service training was conducted to prevent a medication incident from happening again. Corrective action was taken. Two of the four involved with the incident are no longer employed by Silverado. LPA requested Medication Administration Record (eMAR) for July 2024, in-service training and July staff roster relating to this incident. LPA interviewed AD Gill and DHS Retts. LPA visited R1 and observed resident engaging in activities. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Ashiman Gill, AD and Libbie Retts, DHS and a copy of the report was given at the time of the visit.