Incident investigation·November 21, 2024

Licensing Program Analyst (LPA) Steve Chang Conducted an unannounced Case Management - Incident visit and met with Administrator (ADM) Michael Vu. On 11/07/2024, the Department received a death report of resident R1 which stating R1 was sent to hospital on 10/29/2024 due to left shoulder and abdominal pain. R1 died on 10/30/2024, around 2:00AM, facility is waiting for the information of R1's cause of death. On 11/08/2024, the Department received an updated death report of R1 with R1's cause of death. On 11/08/2024, the Department received an updated death report of R1 with description of R1's condition before R1 was sent to hospital on 10/29/2024 morning, and R1's physician report, Appraisal/Needs and Service Plan, Activities for Daily Living Questionnaire for MD review form, and Identification and Emergency Information Form. On 11/21/2024, LPA interviewed staff S1. S1 stated he/she received Colostomy training from Registered Nurse, the licensee to provide Colostomy care to resident R1. S1 stated Licensee and another staff S3 also provide Colostomy care to R1. S1 stated S3 also received Colostomy training from Register Nurse, the licensee. S1 stated R1 was able to feed self. R1 was able to comb self. S1 stated R1 was able to walk with walker or wheelchair. S1 stated he/she and S3 conducted bed bath for R1. LPA interviewed staff S2. S2 stated he/she did not provide Colostomy care to R1. S2 stated he/she cooks meals. Continue on LIC809-C. Page 1 of 2. LPA interviewed Licensee (LCN) on the phone. LCN confirmed he/she provides Colostomy training to S1 and S2 two times per month. LCN stated he/she checked R1's Colostomy bag regularly to make sure it is clean. LCN confirmed he/she also provided Colostomy care to resident R1. LPA interviewed ADM. ADM stated R1 was under restricted health condition for Colostomy. ADM stated the facility is compliance with the regulation. ADM stated staff S1 and S3 received the Colostomy training from registered nurse. ADM stated S1, S3 and the registered nurse provided Colostomy care to R1. ADM provided a copy the facility Colostomy training materials. ADM provided the twice per month Colostomy training log for S1 and S3. Checked LPA's email log with the facility Administrator(ADM), an email from ADM on 10/30/2024 stating resident R1 was sent to hospital due to shoulder pain on 10/29/2024, and the facility will send an official incident report. Based on the review of the incident reports that the facility sent to CCL office, there is no written incident report regarding R1 was sent to hospital. Based on the review of R1's physician report and Appraisal/Needs and Service Plan, R1 is non ambulatory but is not bedridden. Based on the review of the facility fire clearance records, the facility has capacity of 6 non ambulatory residents and capability of 1 bedridden resident. Based on the review of R1's physician report and Appraisal/Needs and Service Plan, R1 used colostomy bag which is restricted health conditions. For today's visit, deficiency noted, citation was issued due to the facility did not send a written incident report of resident R1 was sent to hospital to CCL office within 7 days. See LIC809-D. Exit interview was conducted with Administrator (ADM). This report was provided to ADM for review and signature. A copy of the reports was provided to ADM. Page 2 of 2.