Incident investigation·October 20, 2021

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to the Unusual/Injury Incident Reports (UIRs) for residents (R1, R2, R3 and R4) submitted by the facility to the Department. LPA met with Associate Executive Director Rosana Frias and informed the purpose of visit. LPA also met and spoke with Wellness Director/LVN Valentine Mathangani. UIRs indicated the following: 1. Resident (R1) October 1, 2021 - Home health was providing routine wound care to R1. Wound not improving. Wound was cleansed and treated by the nurse before resident was transferred to the hospital for further evaluation. R1 remains out of the community at the time of the report. 2. Resident (R2) September 25, 2021 - case manager checked at around 5:30 pm and found R2 unresponsive. 9-1-1 was activated and R2 was transported to the hospital. R2 was discharged back to the facility with no new orders; frequent checks initiated 3. Resident (R3) October 3, 2021 - R3 called Hayward Police Department (HPD) for assistance at around 3:30 am, because R3 wants to go to the hospital and talk to her doctor. HPD took R3 to John George. Case manager and R3's physician were notified. 4. Resident (R4) October 1, 2021 - R4 was noted to have swelling on face and puffy eyelids. Staff called 9-1-1 and R4 was brought to the emergency. R4's POA and physician notified. .....continued on LIC809C LPA conducted interviews and obtained the following documents for R1, R2, R3 and R4: LIC602A Physician's Report; Appraisal; hospital discharge document. LPA also obtained copies of home health visit notes for R1. According to Rosana Frias and Valentine Matangani, R1 and R4 did not return to the facility. LPA to review the documents obtained. A follow-up visit will be conducted if warranted. No deficiency cited during today's visit. Exit interview conducted and copy of this report provided.