312700739-4-14-2023-25-AS-LMUZ-CRUTDM-20230515143833

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700739
Report Date: 04/14/2023
Date Signed: 04/14/2023 11:40:56 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2022 and conducted by Evaluator DeAnna Williams-Lyons

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220429171119

FACILITY NAME:	PINES, THE		FACILITY NUMBER:	312700739
ADMINISTRATOR:	ROBERTSON, JOHN		FACILITY TYPE:	740
ADDRESS:	500 W RANCHVIEW DRIVE		TELEPHONE:	(916) 672-5019
CITY:	ROCKLIN	STATE: CA	ZIP CODE:	95765
CAPACITY:	142	CENSUS: 132	DATE:	04/14/2023
		UNANNOUNCED	TIME BEGAN:	09:09 AM
MET WITH:	Henry Cole, Executive Director		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff failed to follow medication order leading to resident's death.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On April 14 2023, Licensing Program Analyst DeAnna Williams Lyons arrived to deliver findings.
LPA met with Executive Director, Henry Cole, and informed him the reason for the visit. Prior to initiating the visit LPA completed COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and wore an N-95 mask for Personal Protective Equipment (PPE).

On 4/29/2022, the Sacramento North Adult and Senior Care Regional Office (RO) received a complaint regarding staff failing to follow medication order leading to the death of Resident 1 (R1).

Allegation: Facility staff failed to follow medication order leading to resident's death.
Resident (R1), was admitted to The Pines (TP) on 4/16/2021.On 4/19/2022, R1 had medication orders from their doctor indicating new medication orders.
To continue see 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 25-AS-20220429171119

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: PINES, THE	FACILITY NUMBER: 312700739
	VISIT DATE: 04/14/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Orders indicated that two medications were to be discontinued. Per the R1's Medication Administration Records (MAR) for April 2022, R1 was given the discontinued from 4/19/2022 to 4/23/2022. Additionally, R1 was given the new medication from 4/20/2022 to 4/23/2022. Per R's death certificate, R1's date of death was 4/28/2022. The cause of death is listed as "Bradycardia, Metabolic Encephalopathy, and Dementia." The staff were interviewed and admitted to not seeing the note for the discontinued medication.

R1 was admitted to ICU due to Hypoglycemia and hourly blood sugar check. An unusual Incident/Injury Report was submitted by Med Tech reported at 3:18 PM. on 04/23/22, R1 was leaning to their right side, sweating, and slowing on their speech, 911 was called and R1 was sent to the Emergency Room for further evaluation.

On 4/21/22, R1 was transferred to the medical unit, became bradycardia, and went into cardiac arrest on 4/28/22. The death certificate indicated, R1's immediate cause of death was listed as "bradycardia" with underlying causes listed as "metabolic encephalopathy (An alteration of brain function or consciousness due to failure of other internal organs).

R1 had new medications added and 2 medications needed to be discontinued per doctor's orders. S1 did not transcribe the discontinued orders into the facility’s Medication Administration Record (MAR) which caused the resident to be administered 2 medications which were discontinued per physician orders.

Based on documents reviewed, interviews conducted, there’s no preponderance of evidence to prove the alleged violation contributed to resident’s death. No coroner's report was associated with R1's death as the cause of death was deemed to be of natural causes, therefore, this allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2