Incident investigation·December 3, 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 on four incident reports submitted to CCL: On 11/20/21 resident (R1) was walking towards the dining room outbalanced and had a fall, facility staff called 911 and paramedics transported R1 to Santa Rosa Memorial Hospital. R1 was diagnosed with dislocation of finger, no new medications were prescribed, responsible parties were notified. Per Administrator, R1 is doing better -On 11/18/21 resident (R2) complained of having a hard time breathing, staff called 911, paramedics transported R2 to Santa Rosa Memorial Hospital then was transferred to summerfield rehabilitation center and does not have a discharge date yet. -On 11/25/21 around 6:45am resident (R3) had their roommate called facility staff alleging that they had a fall, had foot pain, staff found R3 in a sitting position, called paramedics who transport R3 to Sutter Hospital. R3 was diagnosed with anxiety, no new medications were prescribed and responsible parties were notified. During today's visit LPA reviewed discharge documents and R3 was discharged with a follow up appointment on 12/17/21 and lab tests were performed. On 11/29/21 around midnight R3 had an un-witnessed fall while in the bathroom, paramedics were contacted and they transported R3 to the emergency room, resident came back the same day with no new medication. During today's Administrator informed LPA that R3 had another incident on 12/2/21 around 7:40am, R3's roommate came to the office to notify staff that R3 stated that they had an un-witnessed fall, staff found R3 sitting in their wheelchair with no apparent injuries, paramedics were called and R3 was transported to emergency room. Currently, resident is still in the hospital. Administrator agreed to submit discharge documents as soon as the resident comes back. No deficiencies were issued during today's visit.