Follow-up·October 9, 2024

On 10/09/24 around 11:20 AM L. Holmes, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management regarding Unusual/Incident Reports (UIRs) for Residents (R1, R2) and a Death Report for R2. LPA met with Lurinza Bean, Licensee (S2) and explained the purpose of the visit. On 10/01/24 ADM reported the following, “On 9/26/2024 R1 was having a virtual MD appointment, and We Care is requesting the primary care MD approve a request for a hospice evaluation due to recent decline. During appointment, the MD verbally instructed that Licensee, S2 to send R1 to ER for evaluation due to noted change in condition . 911 was alerted. Upon arrival to community, they successfully transported pt to ER for further medical evaluation . Pt conservator informed. Permission given for Hospice Evaluation Continue communicating to St. Mary's Hospital that pt needs a hospice evaluation.” On 10/01/24 ADM reported the following, “On 9/26/2024 at approximately 12:30 PM R2 was observed in her bedroom unresponsive after x3 attempts of arousal by tapping shoulder and verbally calling out her name. Licensee, S2. 911 was alerted. Ambulance arrived and safely transported to Kaiser ER for further medical evaluation. Per ER, R2 will be admitted for further evaluation r/t Pneumonia. R2 remains admitted to hospital as of 10/1/2024. Continue to follow up with RP and Kaiser Hospital for patient’s current status.” On 10/03/24, LPA received a DR for R2; date of death 10/02/24. On 10/04/24 LPA extended condolences to the family and facility, requested a death certificate, LIC602 and any other relevant care notes that happened within the months prior to R2’s death. During the visit LPA reviewed the files for R1 and R2 including but no limited to R1's After visit summary for 09/2024 & 07/2024, R2's for 06/2024 & 09/2023 and Identification and Emergency Information for both. Continued on LIC809C... ...continued from LIC809. -At around 12:17 PM, LPA L. Holmes observed that R2 did not have an updated physician's report. The report in R2's file was dated 03/29/21. Deficiency is cited on the attached LIC 809D. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided to Licensee, Lurinza Bean.