Brookdale Sunwest

Type of visit: Required - 1 Year

On 11/9/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA met with Executive Director, Theresa Ward, Associate Executive Director, Juanita Jackson and Health & Wellness Director, Parminder Singh who were informed of the purpose of visit. LPA toured the Assisted Living and Memory Care Unit with Juanita Jackson. The following was observed, reviewed, and inspected: The physical plant, in general, was in good repair. The facility is operating in the capacity approved by Community Care Licensing (CCL). The buildings and grounds were free from hazards. Outdoor and indoor passageways were kept free of obstruction. LPA inspected a sample of resident bedrooms and bathrooms in the Assisted Living & Memory Care Unit. Resident bedrooms have the required bedding and furniture; such as clean mattresses, night stands, storage space, and sufficient lighting. Room temperatures were comfortable for residents in care. LPA inspected a sample of resident bathrooms; the bathroom appliances were operating in safe and sanitary conditions. LPA measured the hot water temperature in the sampled bathrooms, in which all bathroom sinks measured within regulation. Sampled bathrooms were equipped with non-skid surfaces and grab bars. Bedrooms were equipped with a pull cord system to notify staff of any emergencies. LPA toured the kitchen and dining area. The facility was stocked with a 2-day supply of perishable and 7-day supply of non-perishable food items that were labeled appropriately. The facility had a menu posted and available for review. Dishes, glasses, and utensils were in good condition and stored in a healthful manner. LPA inspected the common areas. Smoke detector were tested and functioning properly. LPA observed several carbon monoxide alarms throughout the facility. Continue on LIC809-C Continued from LIC809 There was a locked and centralized storage area for medications, including refrigerated medications. Medications appeared to be dispensed and documented appropriately. The facility had a designated area for resident files and staff files. All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Random staff and residents' records were reviewed. All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. There was adequate seating in the common areas and several activity rooms. LPA observed several activity posters. The facility was also equipped with a complete first aid kit as well as the first aid manual. LPA inspected the outdoor area of the facility. There was shaded area with seating. Overall, the facility was clean, in good repair, and operating in safe conditions for residents in care. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Theresa Ward.the state’s words, verbatim · CDSS document, Nov 9, 2023

Allegation investigated: Resident was physically abused while in care.

Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to deliver the findings of the above allegation. LPA toured the facility and met with Associate Executive Director Logan Harrison. The investigation included interviews with facility staff, residents, and a confidential source. It was alleged that an unidentified abuser was hitting a resident. Regarding the allegation, “Resident was physically abused while in care,” LPA found that, through interviews conducted, Resident One (R1) was yelling wanting out of the facility, and at the same time, being hit by Resident Two (R2). Two caregivers were in the direct vicinity of the incident and were able to engage both R1 and R2 and were able to redirect them from the area. Both residents did not complain of injury and did not go to the hospital for any treatment as a result of the incident. Due to caregivers being able to diffuse the situation and no injury reported, LPA found that this allegation was UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, where a copy of this report was discussed and given along with a copy of the LIC811 (confidential names list). Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 20, 2023 · control 18-AS-20230106131409

Allegation investigated: Facility lacks sufficient staff to meet the needs of the residents in care.

On 12/28/21 Licensing Program Analyst (LPA) David Cuevas conducted an unannounced visit for the purpose of following up with investigating the allegations above. LPA identified self and was granted entree. LPA met with Associate Executive Director, Eloiza Castellanos who was informed of the purpose of visit. During this investigation LPA conducted the following: Staff and resident interviews, walkthrough of facility, resident record review, facility file review, and made observations. Regarding Allegation: Facility lacks sufficient staff to meet the needs of the residents in care. The department initiated an investigation due to reports that facility lacks sufficient staff to meet the needs of residents in care. Substantiated An initial visit was done to facility on 12/15/21 to initiate investigation, during that visit at approximately 11:30 AM, LPA toured the facility along with Staff# (S1) and observed a total of 1 caregiver in memory unit for 12 residents and 1 caregiver in assisted living for a total of 21 residents, with 1 medical technician to share for both memory and assisted living units. Through interviews with staff it was communicated to LPA that normally caregiver coverage for each unit should reflect, 2 caregivers in each unit and 1 one medical technician to be shared by both units for support during the day hours, and during the overnight hours 1 caregiver in each unit and 1 shared medical technician both units. Although LPA was informed that when staff shortages and gaps occur administrative staff provide support and coverage, per staff and residents interviews this adjustment in not enough to meet the needs of residents. Furthermore, a second follow up visit was conducted on 12/28/21 in which LPA toured the facility grounds approximately 12:30 PM along with S1, and identify facility to yet again have only 1 caregiver in memory unit for 12 residents and 1 caregiver in assisted living for a total of 22 residents, with 1 medical technician to be share for both memory and assisted living units. Furthermore, review of resident records and LPA’s observations identify resident #1(R1) in room # 101, to need a Hoyer lift to help with incontinence care, bathing, and getting out a bed, a task that requires at least 2 caregivers, per staff interviews. Based on the review of staff schedules, interviews, and the needs of R1, facility lacks sufficient staff to meet the needs of residents in care, as such allegation of Facility lacks sufficient staff to meet the needs of the residents in care is being SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where this report, LIC 9099 D, and appeal rights were discussed with and provided to Associate Executive Director, Eloiza Castellanos During a visit conducted on 12/28/21 LPA toured the facility grounds approximately 12:30 PM along with S1, and conducted random interviews in rooms # 117, # 100, # 113,# 205, and room # 202, interviewing residents. Based on collected interviews, 5 out of 5 residents reported to be content with wait time, when receiving assistance from staff. Additionally, review of call light and pendant records shows a pattern of appropriate response to resident’s call. As such the allegation of, Residents are made to wait an excessive amount of time to receive assistance from staff, is being UNSUBSTANTIATED at this time, meaning that although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was done with Associate Executive Director, Eloiza Castellanos were a copy of this report was reviewed and provided.the state’s words, verbatim · CDSS document, Dec 28, 2021 · control 18-AS-20211209160912

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jan 11, 2022

Personnel Requirements (a): (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.This requirement was not met evidence by: During visits to facility both assisted living and memory units had a total of 1 caregiver and 1 shared medical technician to provide care and supervision for residents in care; however, R1 in assisted living required a hoyer lift that would require the need for at least 2 caregiver to operate, This posed a potential risk to the health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Dec 28, 2021

Plan of correction: Facility will evaluate the needs of all residents in care and adjust staffing to ensure residents needs are met. New staffing shedule will be provided to LPA by 01/11/22 for review before difienciency can be cleared.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA’s) Venus Mixon and David Cuevas made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA’s were greeted and granted entry by, Director, Juanita Jackson and explained the purpose of the visit. At the time of visit there were 7 staff and 20 residents present. The facility currently has zero positive or suspected Covid-19 cases. No pools or bodies of water in premises, LPA was informed that no weapons or ammunition is maintained at the facility. During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA's observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer) in all restrooms observed. The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility will contact the resident's physician should there be event of any COVID-19 related illnesses. The facility also has a designated infection control lead and cleans and disinfects the highly touched surfaces during each shift, and as needed. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to Director, Juanita Jackson.the state’s words, verbatim · CDSS document, Nov 8, 2021

Allegation investigated: Staff member mishandled resident resulting in injury

Licensing Program Analyst (LPA) conducted an unannounced visit to the facility in order to deliver findings for the above allegation. LPA met with Administrator, Theresa Ward, and discussed the purpose of the visit. The investigation consisted of records review and interviews with staff. LPA interviewed Staff #1 (S1) who stated that the facility conducted an internal investigation of the above allegation. According to S1, on 10/29/2020, Staff #2 (S2) grabbed Resident #1's (R1's) arm after attempting to retrieve Resident #2's (R2's) purse. According to S1, S2's actions resulted in R1 sustaining bruising to the arm. S1 stated that the facility had determined that S2's actions violated facility guidelines for appropriate conduct; therefore, S2 was terminated on 10/31/2020. Based on the evidence gathered during the course of the investigation, the above allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. Substantiated An exit interview was conducted where this report was discussed and a copy was provided to Ward.the state’s words, verbatim · CDSS document, Jul 20, 2021 · control 18-AS-20201030081423

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jul 21, 2021

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...This requirement is not met as evidenced by: Based on records review and interviews with staff, the Licensee did not ensure that R1 was free from abuse. S2 grabbed R1's arm after taking R2's purse. This resulted in R1's sustaining bruises to the arm. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 20, 2021

Plan of correction: The Administrator agreed to conduct training of Residents Personal Rights for all staff. The Administrator will send proof of training (including topics covered, date of training, and names of attendees) to Department by POC date of 7/21/2021.