Incident investigation·July 30, 2021

Licensing Program Analyst (LPA) Angela Elliott arrived at 1:00 PM unannounced to conduct a case management regarding incidents occurring at the facility. LPA met with Irais Lopez Ortega, Administrator and requested copies of documentation. Community Care Licensing (CCL) received incident report on 7/12/2021 for incident occurring on 7/1/2021 when R1 fell and hit the arm of the chair in their bedroom. R1 started bleeding and swelling on right side of their back. R1 indicated it hurt to breathe. Staff called Administrator who indicated staff should call Emergency Services. R1 was transferred to Saint Helena Hospital and diagnosed with right rib fractures, hemothorax and pneumothorax, traumatic. LPA and Administrator discussed reporting incidents within regulatory time frames. LPA provided Administrator copies of the regulations for 87211 Reporting Requirements. CCL received an incident report on 7/21/2021 for an incident occurring on 7/20/2021. R2 pulled out their foley catheter during a shower. Staff bathed and dressed R2 and put them in the living room. When staff attempted to bring R2 to the breakfast table, they were non-responsive. Staff called Administrator who indicated staff should call 911. R2 was evaluated at Saint Helena Hospital, and admitted with a diagnosis of Urosepsis. LPA was notified R2 went on Hospice on 7/24/2021. Administrator indicated they thought Hospice notification to CCL was discontinued. Administrator was provided copies of 87633 Hospice Care of Terminally Ill Residents and 87465 Incidental Medical and Dental Care regulations. Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights given.