Incident investigation·September 24, 2021

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Licensee, Nick Aquino. LPA conducted risk assessment call with Licensee prior to visit. LPA arrived at the facility and had her temperature checked and was logged into a sign-in sheet. LPA is following up regarding three incident reports received involving resident (R1) who had trouble breathing. On 9/19/21 R1 complained about difficulty breathing and was transported to Santa Rosa Memorial Hospital. R1 has a history of not being able to breathe and had been transferred to Hospital due to their smoking habits. During hospital visit was prescribed a nicotine patch to help them manage the smoking issue. Previously, R1 was instructed to limit cigarette intake and responsible party agreed with Administrator that no more money was going to be provided to R1 until their smoking habit changes. During this visit LPA followed up on death certificates for 2 residents (R2 and R3) who were not receiving hospice care at the time of death. Licensee provided death certificate for R2 who passed away on 3/15/2021 and was not under hospice care. Death certificate indicated that R2's cause of death was adenocarcinoma of the lung with metastasis to right pleura and left lung. Death certificate for R3 who passed away on 8/27/21 is still pending and Licensee agreed to submit it as soon as they receive it. The last incident involving R4 who on 9/17/21 around 5pm complained of having difficulty breathing, paramedics were called and resident was transported to Santa Rosa Memorial Hospital. Responsible parties were notified. R4 was prescribed with chronic sinusitis and new medication was ordered. During today's visit LPA confirmed that R4 is taking medication as ordered by their physician. No deficiencies cited during today's inspection.