complaint·March 20, 2024

Page 2 of 2. On 11/20/2023, R1 complained of shortness of breathe and was placed on oxygen to improve O2 saturation. On 11/21/2023, R1 had an unwitnessed fall where R’s foot got tangled in the footrest of their electric wheelchair. No injured, bruise or skin tears. Paramedics were called via 911 and determined she was uninjured, and resident declined to go to ER. On 11/22/2023, R1 was confused and was taking new antibiotics for UTI where confused can be a symptom of the medication. On 11/23/2023, R1 refused medication, was feeling nauseous and weak and did not have congestion. R1 vomited right before being transported to the hospital. R1 was admitted to the hospital due to testing positive for COVID-19. Based on review of R1’s records, R1 was being monitored for any changes at the facility from 11/01/2023 to 11/23/2023, when R1 was transported to the hospital. Per R1’s Progress Notes, Medication Technician (Med-Tech) and Nursing staff (LVN, LPN, RN) documented R1’s change of condition, medication administration and medication concerns every day. On 11/21/2023, the Department interviewed staff (S1), a caregiver for R1. S1 stated before being admitted the hospital, R1 used oxygen and was not uncommon for resident to complaint about shortness of breath. S1 stated the staff did advise R1 to go to the hospital but R1 would refuse. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.