Incident investigation·December 22, 2023

On this day, 12/22/2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management as a follow-up on the Death Reports and Unusual Incident Reports (UIRs) received by the Department. LPA met with Executive Director (ED) Cayia Henry, and informed the reason for visit. Reports indicated the following: 1. Resident (R1) Death Report Report indicated R1 passed away on 5/09/23 with cause of death unknown. R1 was previously sent to the hospital for increased confusion and complaints of left hip pain. R1 expired at the hospital. R1's son called the facility to inform that R1 passed away.. 2. Resident (R2) Death Report Report indicated R2 passed away on 7/17/23. R2 was found unresponsive, no pulse noted and pale in color. Med-tech on duty called 9-1-1 right away. R2 had a fall on 7/10/23 but refused to paramedics to be transferred to ER. R2 refused paramedics again on 7/12/23; was sent via 9-1-1 for an x-ray appointment on 7/14/23, but refused to stay in the hospital for treatment. R2 again refused to be sent out on 7/16/23 due to distended abdomen, 3. Resident (R3) Unusual Incident Report (UIR) UIR indicated R3 had un-witnessed fall on 12/23/23 and was noted with a bump on the side of R3's head and abrasion on the left knee. 9-1-1 was called and R3 was taken to the hospital. Family member, primary care physician and facility's Wellness Director notified. 4. Resident (R4) UIR UIR indicated R4 was seen lying on the floor screaming for help and complaining of pain of left side of leg and head. R4 was conscious and responsive. 9-1-1 was called and R2 was taken to the hospital. Family member, primary care physician and facility's Wellness Director notified. LPA reviewed residents' files and obtained copies of documents including but not limited to the following: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; Appraisal; facility notes; Post-fall Evaluation; hospital discharge documents. LPA conducted interview. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction of due dates may result in civil penalties. Deficiencies and plan and proof of correction were discussed with ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.