Folsom Countryhouse

Allegation investigated: Staff slapped resident Staff intimidated resident Staff did not report physical abuse of resident Staff do not treat clients with dignity and respect

On 11/8/23, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Director of Nursing Brian Pawloski. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unfounded Staff slapped resident Staff intimidated resident Staff did not report physical abuse of resident Staff do not treat clients with dignity and respect Based on records reviewed and interviews, it was determined that R1 was not slapped or abused by any staff at the facility. Based on interviews conducted, no marks were noticed on R1 after the incident was alleged. Records review indicated that R1 has a history of hallucinations and dementia and regularly says that someone is hitting someone. Law enforcement was involved, did their own investigation, and they did not substantiate the allegations above. Regarding staff not treating residents with dignity and respect, all residents interviewed stated that staff are very respectful to them and other residents, and no one had issues with staff. Staff and resident interviews did not indicate any physical abuse happening at the facility. Based on all this information, all above allegations are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview was conducted with Director of Nursing and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Nov 8, 2023 · control 59-AS-20231012162435

Allegation investigated: Staff are not acknowledging resident's new POA documents.

On 11/8/23, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Director of Nursing Brian Pawloski. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.The results of the investigation are as follows: R1 was admitted to the facility on 7/27/23. Complaint allegations stated that R1 was placed in the facility against their will. Based on records reviewed and interviews, R1 has a family member as their POA. Based on R1’s medical diagnosis, R1 is not able to make decisions including the ability to change their POA. Staff are acknowledging that another family member wants to be POA, however, the facility cannot address that issue. LIC602 states that R1 is not medically competent to change the POA. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview was conducted with Director of Nursing and a copy of this report was provided to the facility. Unfoundedthe state’s words, verbatim · CDSS document, Nov 8, 2023 · control 59-AS-20231026084013

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Insufficient staffing to meet the residents needs while in care

On 10/11/23, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Executive Director Danielle Peck. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.The results of the investigation are as follows: ALLEGATION:Insufficient staffing to meet the residents needs while in care. LPA has reviewed facility schedules, and shifts are covered by multiple staff. There is no evidence to support the allegation that needs are not being met due to staffing. LPA learned that there are at least 2 direct care staff available on each floor during each shift. Residents indicated they feel that their needs are met, and LPA finds no evidence that the current staff level is insufficient. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left at facility. Unfoundedthe state’s words, verbatim · CDSS document, Oct 11, 2023 · control 59-AS-20230817141449

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Resident pushed resident causing hip fracture.

On 05/16/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing received on 05/04/2023. LPA met with Executive Director (ED), Danielle Peck, and explained the purpose of the visit. During the course of investigation, the Department interviewed facility staff, and obtained pertinent documents relevant to the complaint investigation such as, residents’ (R1 and R2) physician’s report, assessments, medical records, staff roster, incident reports, SOC 341, video footage for review. Continue on page LIC 9099-C. Unfounded On 04/28/2023, the facility submitted two incident reports and SOC 341 to the Department for review. According to the first incident report on 04/28/2023 at approximately 4 PM, after the care staff was done assisting another resident near the living room, R1 was on the floor sitting down next to the chairs. R1 denied pain and was able to get up with minimal assistance. R1 was unable to recall how R1 fell. R1’s daughter arrived at the community and R1 complained of pain on right hip. EMS was activated to assess R1 and transported R1 to the hospital for evaluation. Second incident report indicated on 4/28/2023 at approximately 6:30 PM, while community was reviewing the video footage involving R1. R2 was involved and was seen pushing R1 that was trying to grab R2’s cane that has resulted to a fall incident. Fall incident resulted in R1’s hip fracture. The Department requested and received R1 and R2’s physician’s report and assessments for review. According to R1 and R2’s physician’s report, residents are diagnosed with Dementia. R1 and R2’s assessments indicated, both residents needs some supervision. The Department reviewed the video footage of the incident that was submitted by the facility. Video footage shows R1 and R2 in the common area with a care staff. Care staff was seen leaving R1 and R2 to the next room for less than 30 seconds. While staff was at a short distance away from residents, R2 pushed R1 which resulted in a fall. Care staff returned and witnessed R1 on the floor and used a walkie talkie to report the fall. The facility has done their due diligence by activating EMS to access R1, transported R1 to the hospital for further evaluation in a timely manner, notified R1 and R2’s responsible parties, and R1’s PCP. ED submitted facility’s plan to prevent this type of incident from occurring again. Folsom CountryHouse staff will continue to provide positive resident engagement by encouraging residents to participate in scheduled activities. Redirect residents who appear to be agitated to different areas of interest. Appropriate staffing to observe interactions with residents who have had any previous incidents to help prevent issues. Staff to continue to receive training for dementia behaviors and redirection. Based on information above, department concluded the allegation is UNFOUNDED, A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. No citations were issued today. Exit interview was conducted with Executive Director and a copy of this report was provided to the facility. The signature of the Executive Director on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, May 16, 2023 · control 59-AS-20230504164039

Allegation investigated: Resident’s Representative’s request for assistance for resident in care were not responded to in a timely manner. Facility does not have sufficient staff to meet the needs of the residents in care.

On 03/08/2023, Licensing Program Analysts (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Thach Duong. Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Substantiated Resident’s Representative’s request for assistance for resident in care were not responded to in a timely manner. An investigation has been conducted regarding the allegation above. It was noted during interviews that Witness 1 (W1) was visiting R1 at the facility and noticed feces on the toilet seat. W1 asked staff members to clean R1’s bathroom however, staff did not clean the bathroom until a couple days later therefore the allegation is substantiated. Based on the departments observations, interviews conducted, and record(s) reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be SUBSTANTIATED. California Code of regulations are being cited on the attached LIC9099D. Facility does not have sufficient staff to meet the needs of the residents in care. An investigation has been conducted in the allegation above. Review of documents and staff schedules indicate there are enough staff in numbers to meet the needs of the residents in care however, staff stated they were not properly trained to answer immediate requests of residents. Although the facility has sufficient staff in numbers, the facility staff are not sufficient and competent to perform necessary duties due to a lack of training therefore the allegation is substantiated. Based on the departments observations, interviews conducted, and record(s) reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be SUBSTANTIATED. California Code of regulations are being cited on the attached LIC9099D. Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents. Appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 8, 2023 · control 25-AS-20220718160858

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 17, 2023

Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: LPA noticed multiple bathrooms unclean in resident’s rooms, which poses a potential health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Mar 8, 2023

Plan of correction: The administrator will conduct periodic inspections of the memory care unit to check for clean bathrooms. The administrator will meet with staff and provide instruction on reporting unclean toilets to management. A copy of this training shall be submitted to licensing upon completion by 3/17/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 17, 2023

Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to ensure staff are competent to provide services necessary to meet resident needs. This poses a potential health, safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 8, 2023

Plan of correction: Administrator to provide CCL with a plan by 3/17/2023 to ensure personnel will be sufficient in numbers AND competent.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 02/10/2023 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Executive Director (ED), Thach Jimmy Duong, and explained the purpose of the visit. 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 together with ED to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) resident bedrooms, six (6) bathrooms, kitchen, and courtyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and ED completed the infection control domain and facility was found to be in substantial compliance at this time. PPE supplies is adequate. LPA went over PIN 23-02-ASC - UPDATED GUIDANCE ON TESTING, ISOLATION AND QUARANTINE with ED. 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, Feb 10, 2023

Type of visit: POC

Licensing Program Analyst (LPAs) Bethany Mirlohi and Lavinia Muscan arrived unannounced to conduct a POC visit. LPA met with Administrator , during today's inspection. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks. LPA's toured the facility with administrator and observed 4 resident rooms and bathrooms. LPA's observed all 4 resident rooms and bathrooms to be clean and sanitary. LPA cleared deficiency during today's inspection. Administrator to send into LPA a copy of the plan on how they will keep resident bathrooms in a clean and sanitary condition by 3/31/22. In addition, LPA's received LIC308 and administrator certificate of the new administrator. Exit interview conducted and copy of report and letter of clearance was provided.the state’s words, verbatim · CDSS document, Mar 29, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with Administrator Leticia Higares during today's inspection. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks. LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 4 resident rooms and bathrooms, kitchen, common living spaces, and staff areas. There is an upstairs area, however residents have not moved into the upstairs area at this time. In the areas toured no immediate health, safety, or personal rights violations were observed. Administrator stated there are no positive COVID cases at the facility, and they have sufficient amount of PPE. LPA and administrator completed the infection control domain. During today's tour LPA observed 2 of 4 resident bathrooms were unclean with feces present on the floor and toilets. Deficiencies have been cited on 809-D. Exit interview conducted and appeal rights given.the state’s words, verbatim · CDSS document, Feb 28, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Konnor Leitzell arrived at facility to conduct a Case Management Visit. Community Care Licensing (CCL) received an Incident Report (LIC 624) and Report or Suspected Dependent Adult/Elder Abuse (SOC 341) from facility regarding Resident's recent trip to the ER. Prior to initiating the case manage inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA contacted Admin and completed a facility risk assessment, and was sure to apply hand sanitizer prior to entry. Upon entry, LPA was screened and greeted by Ashley Steele (Admin Assistant). LPA then explained the purpose for the visit to admin. During visit, LPA conducted interviews with Jennifer Scarberry (Admin); Officer Limon (Folsom County Police); Staff 1; Staff 2; Staff 3; and Resident. Interviews documented on LIC812's. LPA toured the dining area, kitchen, and Resident's personal room.LPA is requesting the following documents to be submitted to CCL via email at konnor.leitzell@dss.ca.gov or via fax at (916) 263-4744 by COB 8/13/2021: Residents Admission Agreement; LIC602; Charting Notes from move in to current; and discharge papers from recent hospital visits. No deficiencies are being cited as a result of today’s visit. Exit interview conducted and report left at facility.the state’s words, verbatim · CDSS document, Aug 3, 2021