complaint·May 5, 2021

From 2/8/21 through 2/11/21, Resident #1 was not feeling well, had a sore throat and was weak. Per records reviewed, the daughter was contacted each day and was given status regarding the resident. The daughter asked the facility not to send the resident out to the hospital and to keep monitoring the resident because she felt it was side effects from the vaccine the resident had just received. On 2/12/21, the resident was having shortness of breath and oxygen levels had dropped. The facility called 911 and the resident was transported to hospital. The daughter was also notified. Regarding allegation " Staff did not seek medical attention in a timely manner" it is unsubstantiated. During interviews conducted with staff, it revealed the resident was sent out to the hospital on 2/12/21 and was in the hospital for over a week. Sometime during the residents hospital stay a denture bracket belonging to the resident was found on the residents throat. During interviews conducted, LPA learned although the resident was not feeling well after receiving the second dosage of the COVID-19 vaccine, the resident never expressed any discomfort or pain days prior to being sent to the hospital or the day of. Per staff interviews and records reviewed, the resident was eating in small quantities and had no difficulty swallowing. Interviews also revealed the resident was somewhat independent and at times would only need assistance for bathing. Staff indicated the resident would sometimes conduct residents own oral hygiene and would remove the partial dentures for staff to clean. All interviews conducted stated the resident was never seen without the dentures on prior to being sent to the hospital. Some time in 2/20/21, the facility made contact with the hospital and the resident was stable and was going to be discharged. A day later the facility was notified by the residents daughter the resident had passed away. It is unknown if the resident ingested the denture bracket at the facility or the hospital. Regarding allegation "Staff neglect resulted in resident ingesting a foreign object" it is unsubstantiated. Based on LPA's interviews conducted and records reviewed, investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted via telephone with the Administrator and a hardcopy was provided via email for signature. Signatures on hardcopy.