Incident investigation·March 28, 2024

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Kasandra Guerrero, Administrator. During today's visit LPA is following up on four incident reports received at CCL on 3/11/24. The first incident report was reported to CCL on 2/26/24 via email. Per incident report, on 2/26/24 at approximate 12:30pm resident (R1) was observed coughing and being slight short of breath, staff contacted R1's physician who advised them to bring R1 to the emergency room for further evaluation. Responsible parties were notified including CCL. R1 was discharged on 2/28/24. Per interviews conducted with staff, LPA was told that the facility conducted testing for Covid-19 to all residents, but the results were negative. Based on discharge documents, R1 was treated for acute on chronic hypoxemic respiratory failure due to another COPD exacerbation and had a follow up appointment with their physician to discuss further treatment. Second incident report was reported on 2/26/24 via email. Per incident report, on 2/26/24 resident (R2) was also observed having shortness of breath and coughing a lot, R2's physician also advise the staff to transport R2 to the emergency room for further evaluation. Responsible parties were notified including CCL. R2 was discharged on 3/3/24. Based on records review provided to LPA during the visit, R2's discharge documents indicates that they were treated for respiratory failure, recurrent pleural effusion, possible pneumonia and acute kidney injury with some medications were discontinued and others were adjusted. R3 had a follow up appointment on March 8, 2024 to discuss further treatment. Continue on LIC809C... Continued from LIC809... Last two incident reports were regarding resident (R3), reports were submitted via email to CCL on 2/24/24 and 2/26/24 respectively. Per incident reports, on 2/23/24 at approximate 5pm, R3 was observed very confused, lethargic, staff contacted R3's physician and were advised to transport R3 to the hospital for further evaluation. Responsible parties were notified including CCL. On 2/24/24 R3 was discharged from the hospital and passed away on 3/4/24 at 4:29pm. During today's visit, LPA was provided with R3's discharge documents stating that R3 has a diagnosis of dementia, R3 was treated for severe sepsis with acute organ disfunction, and they were admitted to receive hospice services and they passed away on 3/4/24. No deficiencies were issued during today's visit. Exit interview conducted with Administrator and copy of the report was given.