Incident investigation·October 22, 2024

On 10/22/2024, at approximately 12:40 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Incident follow up visit regarding 5 Unusual Incident/Injury Reports (UIRs) and 1 Death Report received by Community Care Licensing (CCL) between 09/23/2024 and 10/22/2024. LPA met with Shelley Reyes, Administrator. Facility is an assisted living community Incident #1 Received by CCL on 09/23/2024 : On 09/22/2024, Resident 1 (R1) was given 1/2 tab instead of the doctor ordered 1/4 tab of Metropalol succ ER 25mg due to a pharmacy error. The pharmacy filled the incorrect quantity and this was discovered by the Facility's med tech after the medication had been given to R1. The Pharmacy was contacted and R1 was placed on 72 hour monitoring for any change in condition. A corrected prescription was processed by the pharmacy and sent to the facility. R1 did not report any change in condition. Incident #2 Received by CCL on 10/7/2024 : On 10/4/2024, Resident 2 (R2) was "accidentally given Protonix 40mg medication" (See LIC809D). R1's primary care physician (PCP) and family were notified and R1 was placed on 72 hour monitoring for any change in condition. R1 did not report experiencing any adverse affects. Incidents #3 & #4 Received by CCL on 10/7/2024 & Death Report Received by CCL on 10/08/2024 : On 10/3/2024, Resident 3 (R3) "had an unwitnessed fall and was found on the floor in [their] apartment by staff when doing safety checks." Another UIR for the same incident stated R3 "had a fall and had leg pain." EMS was called, R3 was sent to the ER, and later R3's family called the facility to report that R3 passed away due to Heart Failure on 10/4/2024. R3 was not on Hospice. On 10/7/2024, the CCL Officer of the Day requested a death report be submitted. Death Report was received on 10/8/2024 and stated that a copy of the death certificate would be requested. Based on record review, R3 was found at 4:00 AM on 10/3/2024. Continued on LIC809C... Continued from LIC809... Facility Administrator provided LPA with a copy of R3's Death Certificate which states cause of death: Cardiogenic Shock, Acute Hypoxemic Respiratory Failure, and Acute On Chronic Congestive Heart Failure. Incident #5 Received by CCL on 10/21/2024 : On 10/14/2024, Resident 4 (R4) "was found on the floor when call light was answered. 911 was called. Resident was taken to the ER for further evaluation." The report states that R4 was discharged to a skilled nursing facility (SNF) on 10/17/2024. Per record review, R4 had previous falls on 7/18/2024 and 9/20/2024 which were not reported to CCL (See LIC809D). Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations, may result in a civil penalty assessment. Appeal rights provided to Administrator. Exit interview conducted with Administrator, whose signature on document(s) confirms receipt .