Freedom Village

Type of visit: Case Management - Other

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit to the facility for the purpose of delivering amendments on the inspection report of the complaint investigation visit dated August 14, 2023. The initially delivered report did not include an assessment for an immediate civil penalty. The amendment was explained and reviewed with a facility representative. A copy of the amended report as well as this present report were provided to a facility representative at the conclusion of the visit.the state’s words, verbatim · CDSS document, Sep 8, 2023

Allegation investigated: Facility staff failed to seek timely medical services Facility failed to safeguard resident's personal item Facility staff failed to notify resident's authorized representative after fall

Licensing Program Analyst, Kevin Saborit-Guasch conducted an unannounced subsequent complaint visit to this facility to deliver findings in the investigation of the above allegations. LPA was greeted and granted entry by facility administrator Joel Niblet after explaining the purpose of the visit and detailing the allegations. Executive Director Jennifer Suckiel was notified of the and assisted with the remained of the visit. During the investigation interviews were conducted with the reporting party, Resident (R) 1’s family members, facility staff, Orange County Sheriff’s Department staff, and a witness. During the course of the investigation facility records were obtained and reviewed as well as hospice records and medical notes from R1’s physician. Regarding the allegation that Facility staff failed to seek timely medical services and that Facility staff failed to notify resident's authorized representative after fall, the investigation revealed the following: R1 was a 93-year-old resident of Freedom Village Senior Living who resided independently at the facility. CONTINUED ON FORM LIC9099-C Substantiated CONTINUED FROM FORM LIC9099 R1 was admitted to the Independent Living portion of Freedom Village on September 11, 2013. R1 was able to manage their own medications and did not require any assistance with Activities of Daily Living (ADLs). R1 was diagnosed with Myeloblastic Leukemia in 2015. R1 decided to decline further treatment and interventions such as transfusions and proceeded with hospice care. R1’s physician reported on his medical notes that by July 7, 2020, R1’s health had declined with shortness of breath and that R1 was becoming weaker due to anemia. On July 20, 2020, R1 independently contracted with Silverado Hospice for palliative care. On July 30, 2020, the hospice staff reported that R1 was alert and ambulatory. On August 1, 2020, R1 sustained an un-witnessed fall. Staff S1 arrived to check on R1 after they called for help with their alert pendant. R1 informed S1 that they fell onto a bookshelf on their right side and complained of pain. S1 evaluated R1 and assisted R1 to their recliner. After the fall, R1 complained of pain and was unable to get up and unable to perform basic tasks. S2 was notified about the fall and they notified hospice and instructed facility staff to initiate two-hour welfare checks on R1. Staff written notes documented R1 remained in bed and was experiencing extreme pain. After the resident’s fall on 08/01/20, staff provided a narrative of the incident, including a red alert report which requires a signature from resident if they refuse transport to the hospital. No signature was included on the report obtained by the Department. On August 2, 2020, staff contacted R1’s son to inform him that his mother’s health had declined. R1’s family came to visit R1 who was now bedridden with complaints of persistent pain. R1 refused to go to the hospital and her family respected her wishes. On August 3, 2020, at about 1030 hours, Hospice nurse S3 contacted the family to inform them that R1’s health had progressively declined. Family arrived at approximately 1130 hours and remained with R1 until they passed at approximately 1330 hours. Due to the rapid deterioration of R1’s health and excruciating pain they experienced, the facility failed to provide timely medical attention regardless of the resident receiving palliative care from hospice. R1 should have been treated for the injury sustained after their fall. Under Title 22, 87101 (7) "Hospice Care Plan" means the hospice agency's written plan of care for a terminally ill resident. The hospice shall retain overall responsibility for the development and maintenance of the plan and quality of hospice services delivered, R1’s fall and injury sustained was not part of R1’s hospice care plan. Under Title 22, Section 87101 regarding Falls, the facility failed to provide timely medical attention and did not report the fall to next of kin in a timely manner. CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C The facility's failure to obtain required medical attention allowed R1 to experience unnecessary pain and injury following the fall sustained on August 1, 2020. Regarding the allegation: Facility failed to safeguard resident's personal item, the investigation revealed the following. Interviews were conducted with R1’s family, facility staff, and hospice care staff. S2 informed R1’s son that S2 had removed R1’s wedding ring and placed it a box for the family. R1’s son received the box but when they opened it, R1’s wedding was not present in the box and some other jewelry was present that R1’s son did not recognize. S2 provided conflicting statements and after admitted to removing R1’s wedding ring, they later recanted that statement. S2 then sent an email confirming they had in fact removed R1’s wedding ring. However, upon removing the R1’s ring, there was no documentation describing what was removed and indicating where the ring was stored for safekeeping. Based on the observations made, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations: Facility staff failed to seek timely medical services, Facility failed to safeguard resident's personal item, and Facility staff failed to notify resident's authorized representative after fall are deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is/are being cited on the attached LIC 9099D. An Immediate Civil Penalty was additionally assessed on today September 8, 2023 for a violation of California Code of Regulations Section 87465(g) resulting in a resident's injury. An exit interview was conducted with the facility representative and a copy of this report along with the appeal rights were provided at the time of this visit.the state’s words, verbatim · CDSS document, Aug 14, 2023 · control 22-AS-20200928144157

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Sep 11, 2023

The California Code of Regulations Section 87465(g) on Incidental Medical and Dental Care states that “The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health”. This requirement is not met as evidenced by: based on resident record review & interviews conducted the licensee failed to call 911 following R1’s unwitnessed fall on 08/01/2020. This poses an immediate risk to the health & safety of residents in care. CIVIL PENALTY ASSESSED ON 9/8/23the state’s words, verbatim · CDSS document, Aug 14, 2023

Plan of correction: Licensee will provide staff an in-service training regarding this regulation by POC due date. Licensee to provide the name of the instructor, their title, and submit written proof of the staff training to LPA by POC due date. The licensee to provide LPA a written statement indicating they have read this section of Title 22 regulation and how exactly they intend to adhere to it by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Sep 11, 2023

The California Code of Regulations Section CCR 87211(a)(1)(A) on Reporting Requirements states that “A written report shall be submitted (…) to the person responsible for the resident within seven days of the occurrence of Death of any resident(…).” This requirement is not met as evidenced by: based on resident record review & interviews conducted Licensee failed to submit Death Report until requested. Licensee also failed to report R1’s fall. This poses a potential risk to the health and safety of the residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2023

Plan of correction: The Licensee is to ensure written reports are submitted to the Department pursuant to this regulation. The Licensee to provide LPA a written statement indicating they have read this section of Title 22 regulation and how exactly they intend to adhere to it by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a)(2) · Plan of correction due date: Sep 11, 2023

The California Code of Regulations Section 87218(a)(2) on Theft and Loss states that “The licensee shall ensure an adequate theft and loss program (…). A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost property (...).” This requirement is not met as evidenced by: based on observation and interview, Licensee failed to properly safeguard R1’s wedding ring. This poses a potential risk to the health and safety of the residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2023

Plan of correction: The Licensee to ensure it always safeguards resident property. Licensee will provide staff an in-service training on regulations applicable to Theft and Loss by POC due date. Licensee to provide the name and title of the instructor, and submit written proof of the staff training to LPA by POC due date.

Allegation investigated: Staff did not follow physician's orders Staff did not facilitate medical tests for resident.

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit for the complaint received on 12/15/2022 for the allegations listed above for a continuation visit, and to deliver the findings. LPA De Perio explained reason for visit and was greeted by facility administrator (AD)-Joel Niblett, Assistant Director-Jackie Arreaga, Clinical Director-Jean Guevara and Assistant Director of Nursing-Marybeth Melby. For this visit, there are a total of 62 residents in care (Assisted Living) of which 12 are on hospice. LPA De Perio conducted a continuation of interviews, and documentation reviews and obtained copies of pertinent documents. (SEE LIC9099-C) Unfounded This department has investigated the complaint alleging that staff did not follow physician's orders. LPA conducted record reviews such as but not limited to: the resident's physician report, medication record, prescribed medication log (including PRN medication), incident reports, physician orders, staff roster, and resident roster. LPA conducted a total of 9 interviews, which consisted of staff, residents, and responsible parties. 9 out of the 9 interviews conducted did not corroborate with the allegation due to reporting that the facility does follow the physician orders. Responsible parties also reported that there were no concerns regarding not following physician orders. Per interview and record review, PRN medications are only given to a resident as needed, and that the resident must request for the medication prior to receiving it. LPA reviewed the PRN medication log of the resident (December 2022) and it has been documented that the facility staff did give the medication (Imodium) to the resident per request between the dates of 12/14/22-12/25/22. Based on observations and review of documents obtained, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This department has investigated the complaint alleging that staff did not facilitate medical tests for resident. LPA conducted a total of 9 interviews, which consisted of staff, residents, and responsible parties. 9 out of the 9 interviews conducted did not corroborate with the allegation. 5 out of the 9 interviews reported that the facility is partnered with a company called "Trident Care", who provides services such as: x-rays, blood work, ultra sounds and urine testing to the residents at the facility, and that once results are received, Trident Care, the facility, the resident's physician and responsible parties (if applicable) remain in communication regarding the resident's condition and results. LPA conducted record reviews such as but not limited to: the resident roster, staff roster, the resident's physician report, resident's medical lab requests, and the resident's medical lab test results. Upon review, it was found that the physician or physician assistant signed the forms as verification that the resident's medical testing was completed and received. Based on observations and review of documents obtained, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. For today's visit, no citations were issued. An exit interview was conducted with Assistant Director-Jackie Arreaga, Assistant Director of Nursing-Marybeth Melby, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Mar 23, 2023 · control 22-AS-20221215100019

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAS) Celine De Perio and Albert Marin conducted an unannounced case management visit at facility to follow up on the incident reports (SIR) that occurred between two residents on 9/16/22 and 9/17/22. LPAs were greeted and granted entry by facility administrator (AD) Joel Niblett, Assistant Director Jackie Arreaga, and Clinical Director Jean Guevara. For today's visit, there are a total of 61 residents in care. LPAs De Perio and Marin conducted a tour of the interior portion of the facility with AD Niblett and toured resident #1's (R1) room and resident #2's room (R2) and conducted interviews with both residents. LPAs De Perio and Marin reviewed the files and Physician's Reports for R1 and R2 LPAs De Perio and Marin discussed California Code of Regulations Section 87466 Observation of the Resident. For today's visit, no deficiency was noted for areas observed. No citation was issued. LPAs De Perio and Marin conducted an exit interview with AD Niblett, Assistant Director Jackie Arreaga, and Clinical Director Jean Guevara, and a copy of this report, along with the regulation discussed was left in the facility.the state’s words, verbatim · CDSS document, Sep 21, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Celine De Perio met with Facility Administrator (AD) Joel Niblett, Assistant Director Jackie Arreaga, and Clinical Director Jean Guevara to conduct an unannounced case management visit to follow up on the technical assistances issued on 7/7/2022 regarding the following: Delayed egress doors are temperamental when opening. Please ensure doors are easily operational at all times - COMPLETED. All delayed egress doors are operational, as it alarms and automatically opens within 15 seconds when pushed. Emergency Disaster Plan (LIC 610) - COMPLETED and posted in a central location. PUB 475 "Let Us Know" Poster - COMPLETED and posted. Note: Per AD, the PUB 475 poster size: "20 X 26" was ordered and a copy of a receipt was provided. Pending delivery. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 18, 2022

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kimberly Lyman and Celine DePero conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPAs were greeted and granted entry into the facility by Administrator Joel Niblett and explained the reason for the visit. Assistant Director Jackie Arreaga and Clinical Director Jean Guevara was present as well. Administrator Joel Niblett has an administrator certificate expiring on 08/15/2023. At 11:05 AM, LPAs toured the facility with the management team. Facility is a three level building with skilled nursing on the first floor. Facility has a library, beauty salon, and multiple visitation areas. Facility has 59 residents in care during today's visit with seven on hospice care. LPAs observed residents relaxing in common areas of the facility as well as in their rooms. All residents appeared happy and well taken care of. Facility appears clean and sanitary. Facility screens all visitors to the facility and LPAs observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a hand written visitor sign in sheet as well as a self temperature taking station. Facility takes resident temperatures daily and documents. Facility has all required department postings. Facility has a mitigation plan as well as the facility's Covid-19 prevention plan. Quick Response Fire Protection conducted a fire inspection on 03/29/2022 and facility tests smoke detectors in-house monthly. LPAs observed ample emergency food and water as well as multiple first aid kits throughout the facility. Facility has sanitation stations spread out through the common areas. Resident's participate in activities such as exercise, games, and music therapy. Facility has an ample supply of PPE, incontinence, and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. Facility rooms are currently single occupancy. LPAs reviewed select resident files and files were complete. Based on the observations made during today’s visit, NO deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Jul 7, 2022

Type of visit: Case Management - Incident

This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Ruth Martinez to follow up on an incident reported to Community Care Licensing. LPA arrived at facility was greeted by receptionist and granted entry. LPA met with Jennifer Suckiel, Executive Director and explained the purpose of today’s visit. Incident was self reported on 04/29/2022 regarding independent living resident R1’s incidents on 04/22/2022. On 04/22/2022 R1 activated red alert pendant, facility nurse responded to the call. Upon arrival nurse observed R1 to be seating upright on the floor by the bed. R1 reports that they were walking towards their bed and they lost their balance and fell. 911 was immediately called and paramedics arrived on seen and transferred R1 to local hospital for evaluation. Facility nurse conducted first aid to R1 until paramedics arrived on scene. R1 indicated to having pain in their right hip, R1 does not have a history of falls. All responsible parties were notified. R1 has not yet returned to the community as they will be check in to skilled nursing for further treatment of fall. R1 is an independent living resident that does not require a needs and services plan. R1 is ambulatory and is able to ambulate independently. R1 will be re-evaluated prior to returning to the community for any changes in condition. LPA found that facility acted appropriately and in a timely manner to address the incident and all other immediate attention to injuries in question. LPA did not observe any immediate and/or safety risks in or out of the facility. This report was reviewed with facility representative and a copy of this report was provided and left at the facility.the state’s words, verbatim · CDSS document, May 9, 2022

Type of visit: Case Management - Incident

This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Ruth Martinez to follow up on an incident reported to Community Care Licensing. LPA arrived at facility was greeted by receptionist and granted entry. LPA met with Jennifer Suckiel, administrator and explained the purpose of today’s visit. Incident was self reported on 03/14/2022 regarding R1’s incidents on 03/08/2022. On 03/08/2022 R1 activated red alert pendant, facility nurse responded to the call. Upon arrival nurse observed R1 to be on the floor of the residents apartment kitchen. R1 reported to have hit the back of the head and a small laceration was observed. Facility nurse conducted first aid to R1 until paramedics arrived on scene. 911 was immediately called and paramedics arrived on seen and transferred R1 to local hospital for evaluation. R1 indicates that they felt light-headed and just fell back, R1 does not have a history of falls. R1 denies the loss of consciousness. All responsible parties were notified and R1 returned to the community. Facility conducted a Wellness check upon return to the facility. R1 followed up with primary physician. R1 has been doing well since incident. LPA found that facility acted appropriately and in a timely manner to address the incident and all other immediate attention to injuries in question. LPA did not observe any immediate and/or safety risks in or out of the facility. Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Administrator and a copy of this report was provided and left at the facility.the state’s words, verbatim · CDSS document, Apr 25, 2022

Type of visit: Case Management - Incident

This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Ruth Martinez to follow up on an incident reported to Community Care Licensing. LPA arrived at facility was greeted at the door by caregiver and granted entry. LPA met with Jennifer Suckiel, administrator and explained the purpose of today’s visit. Incidents were self reported on 12/07/2021 regarding R1’s incidents on 12/01/2021. On 12/01/2021 R1 was in the 3rd floor hallway and did not have a cane for assistance. R1 had forgotten to bring the cane and had an unwitnessed fall. R1 is an independent living resident and does not have a history of falls. EMS was activated and EMT on duty responded to call and immediately performed first aid. Facility immediately called 911 and paramedics arrived to evaluate R1. Resident was transported to hospital for evaluation. All responsible parties were notified and R1 returned to the community. R1 to follow up with primary physician. LPA found that facility acted appropriately and in a timely manner to address the incident and all other immediate attention to injuries in question. LPA did not observe any immediate and/or safety risks in or out of the facility. Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Jennifer Suckiel, Administrator and a copy of this report was provided and left at the facility.the state’s words, verbatim · CDSS document, Dec 16, 2021

Type of visit: Case Management - Incident

This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Ruth Martinez to follow up on an incident reported to Community Care Licensing. LPA arrived at facility was greeted at the door by caregiver and granted entry. LPA met with Jennifer Suckiel, administrator and explained the purpose of today’s visit. Incidents were self-reported on 12/07/2021 regarding R1’s incidents on 11/28/2021. On 11/28/2021 R1 was using the restroom in R1's apartment, R1 was sitting on the toilet when resident slid to the side into the walk in shower. R1 pressed EMS and EMT on duty responded to the call. R1 complained of pain to shoulder and 911 was called. Paramedics arrived to evaluate and treat R1, resident was transported to hospital for evaluation. All responsible parties were notified and R1 returned to the community and is in the skilled nursing section of the facility. R1 referred to skilled nursing for post fall rehabilitation. R1’s care plan does not require bathroom assistance as R1 is not a fall risk resident. LPA found that facility acted appropriately and in a timely manner to address the incident and all other immediate attention to injuries in question. LPA did not observe any immediate and/or safety risks in or out of the facility. Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Jennifer Suckiel, Administrator and a copy of this report was provided and left at the facility.the state’s words, verbatim · CDSS document, Dec 16, 2021

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Norman Woodridge conducted a Covid-19 Annual Inspection at the facility. Upon arrival, LPA completed a Covid-19 Symptom questionnaire and temperature check. LPA met with Executive Director, Jennifer Suckiel, informed Director of the purpose of the visit, and conducted a tour of the facility. The following was observed and discussed: LPA observed Covid-19 stations with Covid-19 questionnaires, hand sanitizer, and signage. It was noted that the facility requires temperature checks for all visitors and staff. LPA observed a 2-day supply of perishables and a 7-day supply of nonperishables. LPA observed 30-day supply of PPE. Hallways and walkways were free from obstruction throughout the facility. LPA and Director discussed updated Covid-19 requirements including Covid-19 signage, testing, staffing, and reporting requirements. No deficiencies were noted during the inspection. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 22, 2021