Brookdale Mirage Inn

Licensing Program Analyst (LPA) Anna Bueno conducted a subsequent unannounced visit to the facility to continue the complaint investigation and deliver findings on the above allegations. LPA met with executive director (ED) Denise Flores who was informed of the purpose of today’s visit. The investigation consisted of staff and resident interviews and review of relevant records. LPA was unable to corroborate the allegation that Staff 1 (S1) inappropriately touched Resident 1(R1). Interview with R1 stated that they do not know who touched them, where they were touched, or how they were grabbed. During the interview with Department staff, R1 was not aware of current events, current date, and personal information about themselves due to their cognitive condition. Department staff interviewed facility staff who stated that S1 has worked at the facility for 10 years. Interview with S1 denied they inappropriately touched R1 or any residents. S1 stated that R1 needed prompting during showers,Read the full finding— CDSS inspection report, June 15, 2023 · control 18-AS-20210503144834

Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegations. LPA met with Executive Director III Denise Flores and explained the purpose of the visit. The investigation consisted of file reviews and interviews with relevant parties. Allegation #1 “Resident sustained a pressure injury while in care”. The allegation alleged that On August 9, 2020, resident # 1 (R1) with bedsore. The reporting party (RP) stated that the stage of the bedsore is unknown. LPA Nickolas’ facility file review revealed that the facility communicated with R1’s physician throughout their stay there. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation # 2 “Licensee did not ensure changes of resident's condition were reported to a physician in a timely manner”. The allegation alleged that an unknown nurse from the facility’s corporate offices visited, saw R1, and immediately sent R1 to the hRead the full finding— CDSS inspection report, April 10, 2023 · control 18-AS-20201102093836

Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegations. LPA met with Executive Director III Denise Flores and explained the purpose of the visit. The investigation consisted of file reviews and interviews with relevant parties. Allegation #1 “Facility staff caused bruising to resident”. The allegation alleged that staff #1 (S1) grabbed resident # 1 (R1) on the resident’s right forearm, leaving a visible bruise. LPA Nickolas' facility file review revealed that S1 no longer works at the facility, and R1 moved out on January 1, 2022. Therefore, both parties were not interviewed during this investigation. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation # 2 “Facility staff handled resident in a rough manner”. The allegation alleged that S1 grabbed resident R1. LPA Nickolas’ investigation into this incident revealed that S1 no longer works at the facility, aRead the full finding— CDSS inspection report, April 10, 2023 · control 18-AS-20201102163741

Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegations LPA met with Executive Director III Denise Flores and explained the purpose of the visit. The investigation consisted of file reviews and interviews with relevant parties. The allegation alleged that resident #1 (R1) was admitted to the hospital on July 8, 2020. The allegation alleged the client had pressure injuries on their back and right calf. LPA Nickolas’ facility file review revealed that R1 was non-ambulatory, according to R1’s physician’s report. However, facility staff could not find all R1’s medical records because R1 moved out of the facility on July 30, 2020, and their files were archived. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. A finding of Unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation dRead the full finding— CDSS inspection report, April 10, 2023 · control 18-AS-20200709152202

Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to initiate the investigation into the above allegation. The LPA met with Executive Director (ED), Usbaldo Martinez, and informed him of the purpose of her visit. On this date staff/resident interviews were conducted, records were reviewed and copies of pertinent documentation were obtained. Regarding the allegation, "Staff failed to respond to call system in a timely manner," it was alleged Resident One (R1) sustained a fall on or around June 02, 2022, activated their pendant for staff assistance and did not receive a response for thirty minutes. Executive Director (ED) Usbaldo Martinez and Assistant Director (AD), Denise Flores, were interviewed. Flores reported staff are to respond within zero to twenty minutes after the call system is activated. Flores reported she was present for the incident involving R1. She reported R1 sustained a fall on June 03, 2022 and, when staff responded, thRead the full finding— CDSS inspection report, June 14, 2022 · control 18-AS-20220608144855

Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to the facility to conduct a complaint investigation into the allegations listed above. LPA met with Receptionist Marcy Rios and explained the purpose of the visit. LPA then conducted a tour of the facility. The investigation consisted of interviews with confidential sources, a review of records, and interviews with staff, and residents. It was alleged that Resident One (R1) had a bed sore on their left butt cheek, which had not been reported by facility staff. During an interview with a confidential source, it was noted that the abrasion to R1’s buttocks was not a pressure wound. It was deemed shearing that caused friction to sustain an abrasion, but not an open wound. Facility record review indicated that the facility staff was caring for the abrasion. Thus, this allegation was Unsubstantiated. It was alleged that Resident Two (R2) needs to wait to have assistance with the toilet. Interviews with residents stated thatRead the full finding— CDSS inspection report, October 27, 2021 · control 18-AS-20211021164216