Complaint·June 17, 2025

9099C-1.. The Pre-Appraisal indicates resident had a pacemaker and had memory issues since it was installed in December 2023, was able to ambulate, showed anxiety and depression, was independent with ADL’s, and needed minimal assistance with eating and medications. Allegation: Questionable death. The allegation states that staff indicated they checked on resident (R1) on the morning of April 22, 2025 (0730 hours) to wash and assist resident but (R1) did not want to get up so staff gave (R1) a bed bath. Staff (S1) stated she and staff (S2) later checked in on (R1) again at approximately 0815 hours and observed (R1) was having trouble breathing. Staff (S1) stated that after a minute or two, (R1) stopped breathing entirely and at that point she called 911 and was given instructions for CPR. The Department investigated the above allegation and obtained the county death certificate which lists the following conditions that contributed to (R1’s) death: Cerebrovascular Accident (lasting minutes), Myocardial Infarction (lasting hours), Chronic Kidney Disease and Hypertension (lasting years). (R1’s) death is recorded at 9:08 am on April 22, 2025 There were no other health conditions that contributed to or resulted in the cause of (R1’s) death that was reported to the Sacramento County Coroner’s office, and there was also no biopsy or autopsy performed. The Administrator explained how (R1) had been refusing medications, starting on 4/7/25 through 4/22/25. LPA was provided with documentation showing (R1) refused ordered medications in the morning and evening on: 4/7/25; 4/9/25; 4/11/25, 4/15/25; refused medications in the morning on 4/10/25; 4/12/25, 4/13/25, 4/14/25, 4/16/25, 4/17/25, and 4/20/25; and refused medications in the evening on 4/19/25. The facility submitted an incident report for an incident involving (R1) calling 9-1-1 on 4/17/25. The Administrator and report indicated that it is not certain what (R1) reported to 9-1-1; however, the fire department came out to evaluate (R1), who was cleared and not taken to the hospital at that time. The Administrator stated that 9-1-1 left the home as “(R1) didn't want to go to the hospital", adding that (R1’s) doctor spoke to them later that day and then on Sunday, 4/20/25, advising (R1) they need to be sent out for a "5150", or mental health evaluation. The incident report further states that (R1’s) Psychiatrist communicated with the responsible person that a 5150 may need to be requested if resident’s behavior continues and because resident was refusing medication, contributing to (R1) pretending to "push a pen in the head" of another resident (R2), but no contact was made. *cont on 9099C-2.. 9099C-2 ..The Administrator stated she spoke to the responsible person, on Sunday, April 20, 2025 and confirmed the police arrived at the facility on that day (10:30 am) and took (R1) to a local hospital. LPA reviewed a second incident report for an incident occurring on 4/20/25 (8:00 am). Staff called (R1) for breakfast and found resident in their bathroom filling the garbage can with water, which flooded the room. (R1) was sent to the hospital for a mental health evaluation. On 4/21/25, the administrator received a call from the hospital that (R1) was cleared for discharge, and their responsible person had requested resident be put on the same medication dosages prior to February 3, 2025, which the hospital agreed to. The Administrator stated (R1) was very tired and groggy upon returning to the facility. Hospital discharge papers, dated 4/20/25, note (R1) was admitted with a diagnosis of Agitation or violent behavior, discharged with a Diagnosis of Dementia with Behavioral Disturbance and to follow up with their primary care physician in 3-5 days. The discharge paperwork also notes (R1) is to begin taking (5) new prescribed medications: Aripiprazole 5 mg; Mirtazapine 15 mg; Prazosin 1 mg; Trazodone 100 mg and Valproic Acid 250 mg. The Administrator stated (R1) returned from the hospital on 4/21/25, with (4) of the medications and the medication, Valproic Acid 250 mg was picked up later that day. The Administrator stated that (R1) was "tired and not able to chew very well"and that (R1) went to sleep as usual on 4/21/25 (at 7:30 pm), did not wake up during the night but had a small amount blood in his underwear, which was normal, at times. The Administrator stated (R1) was previously sent to the Emergency Room for spotting and the facility was advised to hold off on administering Xarelto for (3) days and then resume it. LPA observed this documentation. The Administrator stated in February 2025, Kaiser "decreased but then increased the amount of Depakote" and (R1) also "refused to take this medication, which was a mood stabilizer, now and then, and his situation became worse and worse” until Sunday, April 22, 2025. Documentation shows the medication Depakote and Abilify, also a mood stabilizer, was increased and decreased multiple times starting in February 2025. Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED- A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. *cont on 9099C-3.. 9099C-3- Allegation: Staff did not seek timely medical care for resident. The allegation states that on April 22, 2025, resident (R1) was observed to have blood in their underwear and in the shower. The Administrator stated (R1) went to bed at 7:30 pm on Monday night, 4/21/25 and did not wake up during the night but had a small amount blood in his underwear, which was normal, at times. The Administrator stated (R1) was taking medication for prostate and blood thinner. The Administrator stated (R1) was previously sent to the Emergency Room for spotting and the facility was advised to hold off on administering Xarelto for (3) days and then resume it. LPA observed this documentation. Medication records note (R1) was taking Rivaroxaban (Xarelto) 20 mg oral tablet once daily, which is used to treat AFib (Atrial Fibrillation), and this medication and other anti-coagulants can increase the risk of bleeding. The Administrator stated “often times (R1) was bleeding in the teeth area” and she took (R1) to the dentist where they had a plan to treat the gums and used antibiotic rinse”. The Administrator stated (R1) was taken to many medical appointments, including with specialists, which the responsible person confirmed also. Staff (S1) stated that (R1) would occasionally have a small amount of blood, a couple of drops, and (R1) didn’t ever complain about the medical condition, commenting (R1) used to take blood thinner every day. (S1) stated (R1) was good about taking their medications until April 2025 and would give the reason for refusing medications as they “make (R1) feel sick” every time they’re taken. (S1) confirmed Depakote was initially decreased in February 2025 but later increased and (R1) was good about taking the medications. (S1) stated (R1) was not as happy when they started refusing medications on April 7, 2025. Staff (S2) confirmed the same information. LPA and the Administrator phoned the responsible person on 6/17/25, who expressed she was very happy with the care (R1) received at the facility and confirmed the facility would regularly be in contact with her regarding any medical or medication issues, which she would promptly communicate with (R1's) physician. The responsible person confirmed that (R1) had visited the dentist and there was a treatment plan for the bleeding gums (R1) would experience; however, (R1) would cancel the appointments. The responsible person felt that once (R1's) mental heath was treated, they could then go to the dentist. Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED- A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report left at facility.