Incident investigation·November 15, 2021

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Administrator, Charito Santos. LPA conducted risk assessment with staff. 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 submitted to CCL about resident (R1). On 11/9/21 approximately at 11:40am, R1 was walking towards the dining room using their walker when they felt their legs were weak and had a fall twisting their ankle, staff contacted 911, they were transported to Santa Rosa Memorial Hospital and responsible party was notified. R1 was diagnosed with other closed fracture of distal end of left fibula, R1 had x-rays of left ankle and was provided with a special boot to prevent movement at the injury site. R1 came back to the facility with some medication changes and instructed to schedule an appointment for orthopedic surgery. On 11/11/21 approximately at 9:35am R1 complained of pain in their left ankle, couldn't move nor stand up to go to the bathroom and wanted to be transported to the hospital. R1 was diagnosed with chronic kidney disease, unspecified CKD stage and weakness. During that visit R1's weakness was not clear and was released to go back to the facility with no new medications, staff monitored resident for any changes of condition. During today's visit LPA was informed that R1 had to be transported back to the Hospital due to a head injury. Per Administrator, R1 on 11/14/21 around 4:30pm complained of having a seizure, staff assessed resident who appeared to be shaking, R1 wanted to have an one on one companion and kept ringing the emergency bell then requested to call 911 to have them transport to the hospital. R1 was diagnosed with closed head injury due to a fall. LPA reviewed R1's Physician's report dated 7/20/21 who has a primary diagnosis of epilepsy, diabetes and hypothyroidism. Also, has a secondary diagnose of tibia fracture, acute kidney failure. Per Administrator, case worker is going to schedule a doctor's appointment with R1's primary care to request a referral rehabilitation clinic. No deficiencies were cited during today's inspection.