Incident investigation·May 31, 2022

Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with staff Rwanda Perez to conduct a case management visit regarding self-incident reports (SIR) submitted to CCL. Licensee, Pamela Johnson was not able to come to the facility but was available by phone and gave authorization for staff to sign the report. The first incident occurred on 2/27/22 at approximate 2:40pm resident (R1) called out S1 who found R1 on their knees and stated they blacked out, R1 had a small rug burn on their right knee. S1 contacted 911 who transported R1 to Sutter Hospital, blood work, x-rays of ankle and urinary test were performed. R1 returned to the facility at around 1:00am with a UTI diagnosis and new medication was prescribed. During today's visit LPA reviewed R1's file including Physician's report dated 1/29/22 and care plan dated 2/4/22 indicates that R1 needs assistance with incontinence care. Another incident reported to CCL on 3/13/22 at around 12:30pm S1 went to check on resident (R2) who informed S1 that they couldn't move, was unable to get up from bed to chair. Staff called 911 who transported R2 to Kaiser Emergency Department, they did perform a CT scan, drew blood panel and had a change of condition to bedridden. Responsible parties were notified and agreed that due to R2's change of condition will require a higher level of care including medication management assistance that current facility is not able to provide and R2 was transferred to a Skilled Nursing facility. The last incident was on 5/4/22 around 9:00am resident (R3) was noticed retaining fluids, their skin was clammy, their lower extremities were swollen and staff contacted their Physician who instructed staff to send R3 for further evaluation at the St Joseph Memorial Hospital Emergency Department. R3 had lab work, x-rays and was diagnosed with heart failure, atrial fibrillation stage 4 kidney disease. R3 was admitted to receive hospice services on 5/11/22. On 5/21/22 at around 9:20am R3 passed away in the facility, responsible parties and hospice were notified. No deficiencies cited during today's visit.