Eskaton Village

Type of visit: Case Management - Other

On 9/27/23, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Greg Klick . On 9/13/23, LPA delivered investigation findings for complaint number 59-AS-20230320100736. A date error was found on page 2 of the findings report. LPA has corrected the error and is at the facility to obtain a signature and provide the amended report page. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 27, 2023

Allegation investigated: Facility staff did not adhere to Resident’s special diet. Facility staff did not provide care and supervision during meals which resulted in resident death.

On 9/13/23, Licensing Program Analyst (LPA) Kevin Mknelly arrived unannounced and spoke to Greg Klick, Executive Director, to deliver complaint findings for the above allegation. The Department reviewed resident records, facility records and conducted extensive interviews. The Department finds that the allegations cited above are substantiated. It was determined that on 3/11/23, R1 was provided a meal in their room that contained large pieces of meat. R1 had physician’s orders in place for a mechanical soft diet. Staff, S1, delivered the food to R1’s room and left it unattended while R1 was in the restroom. S1 left the food unattended in order to empty the trash. While S1 was not present, R1 attempted to eat the food which had been delivered, R1 choked on the food left and was found by a medication technician, S2, a short time later. S1 returned to find R1 choking and attended to by S2. CPR was provided and emergency responders were called. Emergency responders found and dislodged a piece of meat from R1’s throat. R1 was transported to an area hospital where they died on 3/15/23 after efforts to treat R1. Cause of death was determined to be due to anoxic cerebral injury, cardiac arrest, and aspiration. Substantiated ** report amended on 9/27/23** Records and statements found that R1 was admitted to this facility on 2/21/23. R1 had a physician’s report (LIC 602) at admission, dated 9/16/22. The 9/16/22 LIC 602 stated that R1 had Parkinson’s disease, cognitive issues, no special diet and hand written notes on the LIC 602 that R1 needs help cutting food. On ** 2/21/23, the facility received a physician’s order for R1’s food to be chopped in general and an order of a mechanical soft diet. (The University of Toledo describes a mechanical soft diet as- Level 2: consists of foods that are moist, soft-texture, and easily swallowed. Meats are ground or finely cut to equal size no bigger than ¼ inch. Or Level 3: includes food that is nearly normal excluding very hard, sticky, or crunchy foods. Foods should not be overly dry and should still be moist and bite sized. https://www.utoledo.edu/depts/csa/caringweb/softdiet.html). The licensee provided records to the investigator that on 3/29/23 training was provided to food service staff regarding Textured Modified Diets and Thickened Liquids that identify a mechanical soft diet for meats to be served ground and moistened with gravy or sauce. The Resident Functional Evaluation provided to the Department for R1, dated 2/21/23 notes R1 requires reminders for eating rather than alternative designation of Needs assistance in cutting food or supervision during meals. A second Resident Functional Evaluation form was submitted, however, it did not identify a resident or evaluator, but identifies resident preferred name of an abbreviation of R1’s name. In this form it is noted: Special diet- Chopped, Types of assistance- cutting of meat, and Eating- Has eating or swallowing difficulties requiring complete assistance and supervision during meals. The resident assessments were reviewed and approved, on a RCFE Assisted Living Prospective Resident Approval Review form, by Assistant Executive Director, Ryan Nakao, Residential Living Advisor, Shanti Willis and Resident Care Coordinator, Chantel Krahn. Staff interviews and records indicated that on 3/11/23, Kitchen Supervisors, S3 and S4, were managing food service. The resident’s food was to be prepared and packaged for R1 to receive in their room. S3 and S4 failed to adhere to the Dietary/ Nursing Communication which was posted for R1. The Aforementioned communication designated R1’s diet of Solids- Mechanical Soft Chopped & Bite Sized. Instead, on 3/11/23, Kitchen Supervisors prepared R1’s meal to include three (3) pieces of meat that were not chopped nor bite sized. The food was placed in a Styrofoam container with a lid and placed in a plastic bag. S3 and S4 were subsequently terminated on 3/24/23 after the licensee completed their internal investigation. For both S3 and S4, the termination letters noted: “…you did not and have not consistently provided supervision necessary to ensure that residents who required special diets actually received them. As a result, multiple residents have received food that was not appropriately prepared for them in accordance with their dietary orders, placing them at risk.” Interviews and records review found that on 3/11/23, at approximately 5:25 PM, caregiver S1 delivered the packaged meal to R1’s room. In a statement, S1 stated that she was unaware of R1’s dietary restrictions and had not been instructed to examine the contents of R1’s meal prior to delivering the meal to R1’s room. S1 acknowledged during interview that S1 left the food unattended in order to empty the trash. While S1 was not present, R1 attempted to eat the food which was delivered, choked and was found by a medication technician, S2, a short time later. The Department’s review of meal preparations procedures in place on 3/11/23 found that S3 and S4 were responsible to ensure that residents’ food be reviewed for quality and dietary accuracy before it is released for delivery to residents. The licensee’s and the Department’s investigations found that S3 and S4 failed to prepare R1’s diet properly and failed to review R1’s food before being packaged for delivery. Procedures did not contain provisions for caregiver review of food and diet when food was to be delivered by staff, as in the case of R1 who was required to remain in their room under quarantine. Therefore, S1 was unaware of R1’s diet restrictions and the contents of the meal when S1 left R1 unattended and R1 was able to access the meal. This procedural oversight resulted in R1 lacking proper supervision and assistance with their meal, consuming improperly prepared food, choking, hospitalization and eventual death. In addition to the failure on the parts of S3 and S4 to properly prepare the food for R1 on 3/11/23, the investigation also found: S3’s and S4’s incidents of, as their terminations letters state- “multiple residents have received food that was not appropriately prepared”- had not been addressed in supervisor action prior to the incident on 3/11/23; that the procedures in place did not address individual meal verification when delivered to resident rooms; and that S1 was not provided appropriate training regarding R1’s dietary needs and assistance with cutting food. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. An immediate civil penalty in the amount of $500.00 is to be assessed for a resident death while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on health and safety code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted. Report reviewed with Executive Director . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 13, 2023 · control 59-AS-20230320100736

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(7) · Plan of correction due date: Sep 18, 2023

General Food Service Requirements (b)(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met based on records and statements that resident was not served a special diet as ordered a physician. This posed an immediate risk to the resident's health and safety.the state’s words, verbatim · CDSS document, Sep 13, 2023

Plan of correction: Policies have been updated and training provided. Licensee will submit a statement that that they will submit an policy to their plan of operations for food service special diets that includes review of food deliveries to resident rooms will be completed by 9/18/23. The addendum will include training of all staff, communication between all staff and checking of correct meals to be served to residents- including for those residents receiving food in their rooms.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Sep 18, 2023

Basic Services (f)(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating… This requirement was not met based on records review, interviews and a resulting death of a resident. Evidence found resident was not provided identified eating assistance. This posed an immediate risk to resident's health and safety.the state’s words, verbatim · CDSS document, Sep 13, 2023

Plan of correction: Training and communications have been updated. Licensee will submit proof of polices and training for ensuring resident care needs and dietary needs are known to caregivers and food service employees by the POC date of 9/18/23

Type of visit: Case Management - Deficiencies

On 9/13/23, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Executive Director, Greg Klick . On 3/20/23, the department received a complaint alleging R1's dietary restrictions were not followed for R1 and that R1 was not provided identified assistance while eating. In addition to the investigated allegations Inspections, records and interviews found that in addition to the failure on the parts of S3 and S4 to properly prepare the food for R1 on 3/11/23, the investigation also found: S3’s and S4’s incidents of, as their terminations letters state- “multiple residents have received food that was not appropriately prepared”- had not been addressed in supervisor action prior to the incident on 3/11/23; that the procedures in place did not address individual meal verification when delivered to resident rooms; and that S1 was not provided appropriate training regarding R1’s dietary needs and assistance with cutting food. This constituted a failure on the part of the administrator to provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and need. Furthermore, the incident report and death report provided by the licensee to investigators failed to be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified and did not include the nature of event and disposition of the case. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Executive Director. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Sep 13, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(h)(5) · Plan of correction due date: Sep 18, 2023

Administrator - Qualifications and Duties (h)(5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs… this requirement was not met based on records and interviews that found insufficent training and oversight over special diet services to residents and supervision of food service staff which contributed to a resident death. This posed an immediate risk to resident's health and safety.the state’s words, verbatim · CDSS document, Sep 13, 2023

Plan of correction: The management eam has discussed and implemented measures.Licensee will submit a statement of specific oversight measures on the part of the administrator to ensure resident care needs are met by the POC date of 9/18/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Sep 28, 2023

Reporting requirements (a) (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified .... This report shall include the …nature of event… and disposition of the case. This requirement was not met based on records of incident and death report regarding R1 on 3/11/23 that failed to report timely and did not contain the nature of the event. This posed a potential risk to residents.the state’s words, verbatim · CDSS document, Sep 13, 2023

Plan of correction: Licensee will submit proof of training for all employyes reposible for reporting to CCL reguarding timeliness of reports and detailed information in the report as outlined in LIC 624 and LIC 624a. POC due by 9/28/23.

Allegation investigated: Facility does not have an operational fire alarm system

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 2/14/23 to conduct a Annual Inspection utilizing the infection control domain. LPA met with the Administrator and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed the departments current required COVID-19 protocols. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA were screened by facility staff upon entering the facility. During the investigation, LPAs Kevin Mknelly and Michael Hood conducted interviews and requested Sacramento Metro Fire inspection documentation pertinent to the investigation. Sacramento Metro Fire inspection reports and statements from inspector EB indicated that they noticed, on 12/7/22 in a routine inspection, that fire alarm system in memory care had an error code and alarm that was repaired by the system company. Staff reports to the inspector indicated that the malfunction had Substantiated been occurring and been silenced by staff prior to repairs being initiated. Inspectors noted that while the alarm system would operate, the system malfunction may not have operated as designed to alert outside responders. Inspectors found that the fire alarm system in the independent living building was off line due to system upgrades. Inspectors found that they had not been notified, plans and permits had not been approved by Metro Fire and that this constituted an immediate risk to resident safety. A fire watch was instituted and the upgrade is ongoing with the oversight of Metro fire. Repairs are due to be concluded 12/15/23. Follow- up inspections on 12/20/22 found MC system to be operating properly and on 1/4/23, IL repairs were still ongoing. Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview was conducted with the Administrator. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 14, 2023 · control 25-AS-20221208104020

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Feb 21, 2023

Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on interviews conducted, the facility did not ensure that they had a completely operable fire alarm system, which poses an immediate health, safety, and personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Feb 14, 2023

Plan of correction: Licensee is now under the direction of Metro fire to repair issues identified. Licnesee will submit a plan of correction identifying the measures of maintaining a fully functioning approved fire alert system and requirements for reporting malfunctions timely.The POC is due 12/21/23 Fire safety violations have a civil penalty assessed.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 2/14/23 to conduct a Annual Inspection utilizing the infection control domain. LPA met with the Administrator and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed the departments current required COVID-19 protocols. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA toured the interior and exterior of the independent (IL) living, assisted living (AL) and memory care (MC) buildings and grounds of the facility to ensure health and safety of residents in care. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Infection control Leader completed the infection control domain and facility was found to be in substantial compliance at this time. LPA is aware of fire safety requirements recently in process of repair and upgrade. These issues are addressed in a separate report. LPA requested licensee update their staff roster in Guardian to accurately reflect current employees, submit an LIC 500 and proof of liability insurance. During today's visit, LPA was provided a new mobile phone contact number. No deficiencies are being cited as a result of this inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Feb 14, 2023

Allegation investigated: Staff inappropriately touched resident

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Resident Care Coordinator, Chantel Krahn, to deliver findings into the complaint allegation listed above. LPA wore a surgical mask and was screened by facility upon entry. Facility staff wore masks at the facility. During the investigation, the Department conducted interviews pertinent to the investigation. Allegation: Staff inappropriately touched resident LPA conducted visit on 11/23/2022. Interview with Assistant Executive Director, Ryan Nakao, indicated that no one with the name of the alleged suspect reported had been employed at the facility. No other information regarding the alleged victim or the alleged suspect were provided in the complaint. ** Report continued on 9099-C ** Unfounded Based on interviews conducted by LPA, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with Resident Care Coordinator and a copy of this report was provided to the facility. The signature of the Resident Care Coordinator on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Dec 9, 2022 · control 25-AS-20221121165837

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Resident Care Coordinator, Chantel Krahn, to conduct a case management visit regarding an incident report received by the Department involving potential theft. LPA wore a surgical mask and was screened by facility upon entry. Facility staff wore masks in the facility. During visit, LPA requested and obtained documentation pertinent to the incident. At this time, further investigation is needed regarding information provided. No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Dec 5, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 9/7/22 to conduct a Case Management visit. LPA was Joined by Stacy Barlow and Ellie Holloway. LPA the Executive Director and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required Department COVID-19 protocols. LPA completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA toured the interior and exterior of the facility in independent living, assisted living and memory care. In the areas toured no immediate health, safety, or personal rights violations were observed. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Sep 7, 2022

Allegation investigated: Staff do not respond timely to the residents call alerts while in care

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the investigation and deliver complaint findings to a complaint received on 1/10/2022. LPA met with Erik Olson, Assistant Executive Director and Evelyn Stinebaugh, Resident Care Coordinator. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE): KN95 mask. During the course of the investigation, LPA interviewed Assistant Executive Director, Memory Care Director, (2) Med-Tech/caregivers and (3) residents in Assisted Living Unit. LPA reviewed records of call button/pendant response times for Assisted Living Unit and quarterly survey results for Q42021 and Q12022. The results of the investigation are as follows: cont on 9099C.. Unsubstantiated Allegation: Staff do not respond timely to the residents call alerts while in care Complaint alleges that a resident used their pendant to call for assistance on several occasions in January 2022 and staff took over an hour to respond to each call. The specific resident's name was not provided. Interviews with Med-Tech/caregiver staff indicated that staff works as a team, regardless of which hall they are assigned to, with one staff stating "the lights belong to all of us". Staff also indicated that pendant calls can be "random", many calls are for non-emergencies and pendant response times can vary, with mornings being the busiest, and they are not aware that it has ever taken staff an hour to respond. Staff stated that when a resident pendant button is pushed, it will send an alert to their pagers immediately and to the front desk receptionist at the same time, who will assist by announcing on staff radios that a particular resident has asked for help. Staff confirmed there is not a receptionist at the desk on evenings and weekends to check for call lights with one staff stating if she sees that a call light is not being answered timely, she will announce it on the radio for other care staff to respond to. One staff stated that the response times for March 2022 have been shorter due to an extra person or "floater" assisting caregivers. Staff indicated that on the morning and evening shifts, there are always 4-5 staff on shift and there are always at least 2 staff, 1 caregiver and 1 Med-Tech, during the overnight shift. Another staff confirmed that sometimes staff will forget to clear a pendant after the call has been answered which could reflect a longer response time in the system. Residents interviewed stated it depends on how busy staff is and how many staff are working with another resident stating he has not had to wait more than 30 minutes and some calls are answered in as few as 5 minutes. All residents interviewed indicated they have never had to wait for an hour for assistance. Documentation reviewed of pendant response times for period 1/1/2022- 1/14/2022 show an average response time of 10 minutes. Additional documentation reviewed is from 207 combined resident and resident representatives surveyed for period 10/1/2021- 1/27/2022, which reflects a 94% overall satisfaction rate with staff responsiveness to residents' needs ranking 95-98% percent. Based on information obtained, LPA finds the allegation to be Unsubstantiated- Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview with Resident Care Coordinator. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 23, 2022 · control 25-AS-20220110100005

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Erik Olson, Assistant Executive Director and Evelyn Stinebaugh, Resident Care Coordinator. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE): KN95 mask. LPA, Assistant. Executive Director and Resident Care Coordinator toured the interior of ALU, including the medication room, staff break room, bathroom, common areas and resident hallways. LPA observed all areas toured to be clean, in good repair and odor free and the bathrooms to have hand-washing posters, paper towels, soap and trash cans with lids. LPA observed various Covid-19 posters posted throughout both areas of the facility and at the entrances to each unit. LPA, Assistant Executive Director and Resident Care Coordinator completed the infection control domain, and the facility was found to be in compliance at this time. Inside temperature was observed to be 73* F. Vaccination status of residents and staff were discussed, as well as visitation protocols per PIN 22-07 issued 2/7/2022. Facility is maintaining documentation of visitor vaccination or negative test result. Staff testing requirements were also discussed. LPA observed signage posted at the front entrances that masks are required upon entry. LPA requested a copy of LIC500 and current liability insurance be emailed to CCLD by 3/31/12022. There were no deficiencies observed during today's inspection. Exit interview. Copy of report provided to Resident Care Coordinator.the state’s words, verbatim · CDSS document, Mar 23, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Eric Olson, Assistant Executive Director and Laura Zamora, MCU Director. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. Additionally, LPA was screened per Covid-19 precautionary measures upon entering each area of the community, using AccuShield. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. The facility is licensed for (500) residents, which includes a Memory Care Unit (MCU) for 20 residents, an Assisted Living Unit (ALU) for 40 residents, and skilled nursing unit and Independent LIving Census is currently (19) in MCU and (34) in ALU. ILU was not toured during today's annual inspection. LPA, Assistant. Executive Director and MCU Director toured the interior of MCU and ALU, including resident rooms, dining rooms, staff bathrooms, medication rooms, and common areas. LPA observed multiple residents in MCU to be sitting in the common area, watching television and residents in ALU to be in their rooms. LPA observed all areas toured to be clean, in good repair and odor free and the bathrooms to have hand-washing posters, paper towels, soap and trash cans with lids. LPA observed various Covid-19 posters posted throughout both areas of the facility and at the entrances to each unit. LPA, Assistant Executive Director and MCU Director completed the infection control domain, and the facility was found to be in compliance at this time. Inside temperature was observed to be 73* F. LPA, Assistant Executive Director and MCU Director discussed vaccination status of residents and staff in each unit, as well as visitation protocols per PIN 21-40, issued 8/27/2021. LPA observed signage posted at the front entrances that masks are required upon entry. Staff testing requirements were also discussed. LPA requested a copy of LIC500 and current liability insurance be emailed to CCLD by 1/6/2022. There were no deficiencies observed during today's inspection. Exit interview. Copy of report provided to Assistant Executive Director.the state’s words, verbatim · CDSS document, Dec 29, 2021