Complaint Investigation Report

9099C-1.. The Pre-Appraisal indicates resident had a pacemaker and had memory issues since it was installed in December 2023, was able to ambulate, showed anxiety and depression, was independent with ADL’s, and needed minimal assistance with eating and medications.

Allegation: Questionable death. The allegation states that staff indicated they checked on resident (R1) on the morning of April 22, 2025 (0730 hours) to wash and assist resident but (R1) did not want to get up so staff gave (R1) a bed bath. Staff (S1) stated she and staff (S2) later checked in on (R1) again at approximately 0815 hours and observed (R1) was having trouble breathing. Staff (S1) stated that after a minute or two, (R1) stopped breathing entirely and at that point she called 911 and was given instructions for CPR.

The Department investigated the above allegation and obtained the county death certificate which lists the following conditions that contributed to (R1’s) death: Cerebrovascular Accident (lasting minutes), Myocardial Infarction (lasting hours), Chronic Kidney Disease and Hypertension (lasting years). (R1’s) death is recorded at 9:08 am on April 22, 2025 There were no other health conditions that contributed to or resulted in the cause of (R1’s) death that was reported to the Sacramento County Coroner’s office, and there was also no biopsy or autopsy performed.

The Administrator explained how (R1) had been refusing medications, starting on 4/7/25 through 4/22/25. LPA was provided with documentation showing (R1) refused ordered medications in the morning and evening on: 4/7/25; 4/9/25; 4/11/25, 4/15/25; refused medications in the morning on 4/10/25; 4/12/25, 4/13/25, 4/14/25, 4/16/25, 4/17/25, and 4/20/25; and refused medications in the evening on 4/19/25.

The facility submitted an incident report for an incident involving (R1) calling 9-1-1 on 4/17/25. The Administrator and report indicated that it is not certain what (R1) reported to 9-1-1; however, the fire department came out to evaluate (R1), who was cleared and not taken to the hospital at that time. The Administrator stated that 9-1-1 left the home as “(R1) didn't want to go to the hospital", adding that (R1’s) doctor spoke to them later that day and then on Sunday, 4/20/25, advising (R1) they need to be sent out for a "5150", or mental health evaluation.

The incident report further states that (R1’s) Psychiatrist communicated with the responsible person that a 5150 may need to be requested if resident’s behavior continues and because resident was refusing medication, contributing to (R1) pretending to "push a pen in the head" of another resident (R2), but no contact was made. *cont on 9099C-2..