Follow-up on corrections·June 14, 2024

06/14/2024 10:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Jaime Calloway. Today’s visit is regarding a death report tht was submitted to licensing on 06/10/2024 by the facility concerning a death that occurred at the facility on 05/12/2024 and was reported to licensing on 5/13/2024. Resident 1 (R1) was not on hospice. Per the coroner’s report the immediate cause of death was ACUTE HYPOXIC RESPIRATORY FAILURE, the secondary cause of death was ASPIRATlON PNEUMONIA and DYSPHAGIA. It was reported that on 5/11/2024 R1 was having difficulty breathing, staff called 911 and R1 was transported to the local emergency room for treatment. R1 was evaluated by hospital staff, placed on comfort care, and passed away on 5/12/2024. During the course of the investigation, it was learned that R1 was generally declining in health status over time. R1 had a swallow test performed at the hospital and at a skilled nursing facility and both times it was determined that R1 did not require a modified diet. The facility had been feeding R1 a soft diet since he was discharged from the hospital 2 weeks prior to his death. R1’s family wanted R1 to come back to the facility after discharge from the hospital rather than go to skilled nursing. Even though the administrator had doubts as to whether R1 should come back to the facility based on R1’s declining health status, he allowed R1 to come back. It was determined that R1 was beyond a cceptance and retention limitations of the facility based on his health status upon discharge from hospital, and recent admissions to skilled nursing. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Jaime Calloway.