Incident investigation·October 25, 2021

This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Kathrina Chin to follow up on an incident reported to Community Care Licensing. LPA spoke to with Claudia Luska, Executive Director over the telephone and met Celeste Gonzalez, Administrative Assistant and explained the purpose of today’s visit. LPA made a case management visit in order to address five incident reports dated 9/17/2021, 9/28/2021, 10/8/2021, 10/9/2021, and 10/20/2021. The following incidents occurred: It was reported that resident 1 (R1) on 9/17/2021 who resides in the Dementia Unit fell on his way to the bathroom. He sustained a hematoma to his left eye and left forearm skin tear. The facility called 911 emergency personnel and transferred to UCI Medical Center. R1 remains in Rowntree's skilled nursing facility. On 9/28/2021, Resident 2 fell at the courtyard and hit her head on the pavement and was bleeding. The facility dialed 911 emergency personnel. R2 sustained three staples on her head. Resident has returned to the community. There are two incidents concerning resident 3 (R3) on 10/8/2021 and 10/9/2021. It was reported on 10/8/2021 that R3 fell in the bathroom and sustained a laceration to her head. The facility called 911 emergency personnel and sent her to West Anaheim Medical Center. She returned to the community at 4:20 AM. On 10/9/2021, a nurse checked on R3 and found the resident was more lethargic and the 2 staples on her head was bleeding excessively. The nurse contacted 911 emergency personnel and the resident was taken to UCI Medical Center. R3 remains at Rowntree's skilled nursing facility. Resident 4(R4) fell in her room and had right hip pain and 911 emergency personnel was contacted. Resident was taken to Garden Grove Hospital. R4 sustained a hip fracture and is currently at Rowntree's skilled nursing facility. Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy was provided.