Braswell's Mediterranean Gardens

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the mentioned allegations. LPA met with Kara Richardson Customer Liaison who was informed of the purpose of the visit and allegations. The investigation consisted of interviews with outside parties, staff, residents, record review, and observations. LPA Allen conducted an interview with Resident 1 (R1) who stated a staff member dropped coffee on their leg and foot while serving them breakfast in bed. R1 stated they could not recall who the staff member was, but there was a witness who could possibly confirm the allegation. LPA attempted to interview Resident 2 (R2) but they could not confirm or deny the allegations. The interviews with staff members have stated they observed unexplained scaring thought to be burns on R1’s body but no longer believe R1 was ever burned, and the scaring has inproved since additional care has been provided. UnsubstantiatedRead the full finding— CDSS inspection report, September 19, 2024 · control 56-AS-20240917173429

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility to initiate the complaint investigation and deliver findings. LPA met with administrator Keely Miller who was informed of the visit. The investigation consisted of observations, records review, and interviews with residents and staff members. Allegation 1. The residents and staff members stated alternative measures were taken to ensure staff and residents had access to water while the water was turned off by the water company. LPA observed an overflow of water in the administrator’s office, and running water througout the facility. It was observed that additional water was purchased. Allegation 2. Interviews conducted with facility staff, facility residents, and records reviewed revealed there are no residents that require, or are receiving wound care. UnsubstantiatedRead the full finding— CDSS inspection report, August 5, 2024 · control 56-AS-20240801095457

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to investigate and deliver findings for the allegation listed above. LPA stated the purpose of the visit, was granted entry, and met with Administrator Keely Miller. The investigation consisted of resident interviews, staff interviews, and document review. For allegation, Staff withheld residents debit card. It was alleged that the facility had Resident R1’s debit card in their possession. Interviews with the staff revealed that Resident R1 is self-responsible and does not have a conservator or power of attorney. It was revealed that R1 requested the facility to secure R1’s debit card in a lock box in the front office. R1 signed a document on upon admission on 2/22/2024 allowing the facility to safeguard R1’s debit card. The facility provided R1 full access to obtain the debit card when requested. The staff denied withholding the debit card from R1. UnsubstantiatedRead the full finding— CDSS inspection report, March 15, 2024 · control 56-AS-20240311093246

**This is an Admended report**** Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Keely Miller, Administrator and discussed the purpose of the visit. Regarding the allegations, staff put poison in residents’ food and staff put animal feces in residents’ food. LPA toured the kitchen and did not observe toxins stored in food areas. Staff interviewed deny putting poison and animal feces in residents' food. Six (6) residents interviewed stated they have not had food poisoning and have not witnessed staff put feces in residents’ food. Regarding the allegation, Lack of supervision resulted in resident being hit by another resident. It is alleged that a resident was hit by another resident and staff did not intervene. Staff interviews reveal, staff do intervene when they witness any altercations between residents. Five (5) out of (6) residents interviewed deny witnessing a resident being hit and staff not intervening. Based oRead the full finding— CDSS inspection report, February 9, 2024 · control 56-AS-20240202150207

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the mentioned allegations. LPA met with Christel Hill -Receptionist who was informed of the purpose of the visit and allegations. LPA Allen conducted an interview with Resident 1 (R1) who stated no one at the facility has caused them any physical harm nor has anyone threatened them. R1 was asked about being financially abused while at the facility and R1 stated they have not been financially abused because they handle their own finances. R1 stated there were problems at a prior facility but the problems have since been resolved. LPA Allen observed documents that state R1 is responsible for their own finances. Based on the interview and records reviewed the above findings are Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occuRead the full finding— CDSS inspection report, September 25, 2023 · control 56-AS-20230922170725

Licensing Program Analysts (LPAs) Tricia Danielson and Cheryl Goodrich arrived to the facility unannounce to conclude an investigation into the allegation listed above. LPAs identified themselves and met with Administrator (AD) Keely Miller. LPAs discussed the purpose of the visit and the elements of the allegation AD Miller. Regarding the allegation "staff took advantage of resident's visual impairment", it was alleged that Staff #1 (S1) removed their eyeglasses to hide their true identification from Resident #1 (R1) and due to R1's poor eyesight, identified themselves as someone else to R1 in an effort to get R1 to take their medication. Interview conducted with AD Miller revealed the incident did occur as alleged. Per AD Miller, R1 will not take their medications from S1. R1 has cataracts and S1 attempted to conceal their true identity from R1 by removing their own glasses to make R1 believe S1 was another staff member. R1 and S1 were unable to be interviewed. Based on LPAs observatRead the full finding— CDSS inspection report, June 12, 2023 · control 18-AS-20210310152940

Licensing Program Analyst (LPA) Bernadette Allen arrived at the facility unannounced to deliver the complaint investigation findings for the allegations listed above. LPA met with Keely Miller Administrator. Allegation #1 Personal Rights Violation of a Resident LPA interviewed four (4) staff members who said that the residents’ personal rights have not been violated. Staff members said that all residents are spoken to with dignity and respect. Interviews were conducted with four (4) four residents who said that staff members have not spoken or handled them in an inappropriate manner. During the interviews with residents, they were asked do they feel that their personal rights have been violated by staff members and they said no and that they are treated right/nice by the staff members. Allegation #2-Facility is in disrepair LPA Allen toured the facility, and it didn’t appear to be in disrepair inside or outside. UnsubstantiatedRead the full finding— CDSS inspection report, May 25, 2023 · control 56-AS-20230217095043

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to conclude an investigation into the allegations listed above. LPA met with Receptionist Christelle Bunney and explained the purpose of the visit. Administrator Keely Miller was unavailable due to weather. During today's visit, LPA interviewed one (1) staff and three (3) resident. Regarding the allegation "Staff are rough with residents". it was alleged that Staff #1(S1) and Staff #2 (S2) are rough when turning residents and will push them or drop them. Thirteen (13) residents were interviewed and an additional interview was attempted with one (1) other resident however, they were found to be non-verbal. Seven (7) staff were also interviewed during the investigation. Seven (7) of thirteen (13) residents interviewed reported although they had not been directly handled roughly by S1 but they had heard that S1 is rough with residents but could not specifically state who the heard the information from. Four (4) of the seRead the full finding— CDSS inspection report, March 3, 2023 · control 18-AS-20210121081555

Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegation listed above. LPA met with Christelle Bunney and explained the purpose of the visit. Administrator Keely Miller was unavailable due to weather. Regarding the allegation "Facility has bed bugs", it was alleged that although the facility sprays to mitigate the spread of bed bugs, the facility is not treated professionally by an exterminator for bed bugs. Interview with AD Miller revealed the facility maintains an ongoing battle with bed bugs. The faciltity follows an established protocol following the discovery of any new outbreaks of bed bugs which includes obtaining a doctor's order for cream, showering the resident and applying the cream, moving the resident out of the room, stripping and washing the resident's bedding, washing all the resident's clothing, spraying the room, fog bombing the room and cleaning the carpets before the resident can return toRead the full finding— CDSS inspection report, February 28, 2023 · control 18-AS-20201022150841

Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegation listed above. LPA met with Christelle Bunney and explained the purpose of the visit. Administrator Keely Miller was unavailable due to weather. Regarding the allegation "Facility did not adhere to admission agreement", it was alleged that Resident #1(R1) was not receiving assistance with showers as indicated in their admission agreement. Interview with AD Miller indicated R1 was an independent resident and was not entitled to assistance with showers, but did receive assistance if staff had availability. Miller also indicated R1 was not charged for this service and came to expect it. Review of R1's Physician's Report revealed R1 had mild cognitive impairment, lacked the capacity to bathe theirself, and was unable to manage medications. R1's Appraisal/Needs and Services Plan also revealed R1 was to received shower assistance twice weekly. Review of R1's AdmRead the full finding— CDSS inspection report, February 28, 2023 · control 18-AS-20201008162354

Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegation listed above. LPA met with Receptionist Christelle Bunney and explained the purpose of the visit. Administrator Keely Miller was unavailable due to weather. Regarding the allegation "Resident sustained an injury while in care", it was alleged that Resident #1(R1) was unsupervised causing them to trip over a sprinkler and knock out their first row of teeth. Records reviewed did not indicate R1 required constant direct supervision. Review of R1's Physician's Report revealed they are able to leave the facility unassisted and did not have wandering behavior. Review of R1's Appraisal/Needs and Services Plan revealed R1 liked to walk around the parking lot area of the facility for exercise. Interviews conducted with facility staff revealed R1 routinely walked the property for exercise and this incident occurred in the front of the facility in a grassy area wherRead the full finding— CDSS inspection report, February 28, 2023 · control 18-AS-20201110092924

Licensing Program Analyst (LPA) Tricia Danielson arrived to the facility to conclude a complaint investigation into the allegations listed above. LPA met with Christelle Bunney and discussed the purpose of the visit. Administrator Keely Miller was unavailble due to weather. Regarding the allegation "Questionable death", it was alleged that Resident #1 (R1) was killed by the facility due to dehydration. Review of R1's death certificate revealed the immediate cause of R1's death was attributed to cardiac arrest with underlying causes attributed to respiratory arrest and chronic obstructive pulmonary disease. R1's death certifcate also lists hypertension, peripheral vascular disease, osteoporosis, depression, and glaucoma as significant conditions contributing to R1's death but not resulting in the underlying cause of death. There were no other causes of death listed. Regarding the allegation "Facility staff did not follow resident's prescribed diet", it was alleged that R1 was not providRead the full finding— CDSS inspection report, February 28, 2023 · control 18-AS-20200925094514

Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegation listed above. LPA met with Receptionist Christelle Bunney and explained the purpose of the visit. Administrator Keely Miller was unavailable due to weather. Regarding the allegation "Facility has bed bugs", it was alleged bed bugs are on the resident's beds. Interview with AD Miller revealed the facility maintains an ongoing battle with bed bugs. The facility follows an established protocol following the discovery of any new outbreaks of bed bugs which includes obtaining a doctor's order for cream, showering the resident and applying the cream, moving the resident out of the room, stripping and washing the resident's bedding, washing all the resident's clothing, spraying the room, fog bombing the room and cleaning the carpets before the resident can return to the room. Review of the facility's pest control invoices indicated the facility was treated on 10Read the full finding— CDSS inspection report, February 28, 2023 · control 18-AS-20210121081555

****This is a copy of Original 9099 dated 9/20/2021, investigation conducted by LPA Jennifer Semin*** Licensing Program Analyst (LPA) Jennifer Semin arrived to the facility unannounced to initiate a complaint investigation and deliver the findings for the allegations listed above. LPA met with Administrator Keeley Miller. The investigation consisted of facility record review and interviews with relevant parties. Regarding the first allegation, Facility has bedbugs. The facility has a monthly contract for extermination services thru Pro-Active (a pest control company) and invoices obtained by LPA indicate that the facility was actively being sprayed for bedbugs on 8/16/2021 and 8/25/2021. Interviews with residents in the affected rooms stated they did not have bedbugs after the pest control service and staff cleaning and disinfecting. In addition to spraying, facility is discarding all linens in problem rooms as well as cleaning and treating furniture and mattresses that may be affectedRead the full finding— CDSS inspection report, February 16, 2023 · control 18-AS-20210913091933

Licensing Program Analyst (LPA)Bernadette Allen arrived at the facility unannounced to initiate a complaint investigation and deliver the findings for the allegations listed above. LPA met with Administrator Keely Miller. The investigation consisted of file review, observations, and interviews with six (6) staff members and nine (9) residents. The nine (9) residents said that their rooms are cleaned daily by them or the staff. The residents were asked how often does the staff change their linens and they said once a week or more if needed. The resident in question was interviewed with the assistance of (S1) who translated the interview with (R1) who said that their linens are changed weekly or as needed, their incontinence needs are always met, and they always have clean water to drink. During the visit LPA observed that (R1) had clean drinking water on the side of their bed, there was clean linen on the bed and another staff member came to assist the resident with their grooming needsRead the full finding— CDSS inspection report, February 9, 2023 · control 56-AS-20221123134303

Licensing Program Analyst (LPA) Bernadette Allen arrived at the facility unannounced to initiate a complaint investigation and deliver the findings for the allegations listed above. LPA met with Administrator Keely Miller. The investigation consisted of observations and interviews with six (6) staff members and nine (9) residents. The residents interviewed were asked if any staff member(s) have ever hit them, handled them in a rough manner, or spoken to them in an inappropriate manner. The nine(9) residents stated that the they have never been hit by a staff member(s) or handled in a rough manner and the staff has never spoken to them in an inappropriate manner. The six (6) staff members interviewed said that there hasn't been a time when they have seen or heard of another staff member(s) hitting a resident, or treating the residents in a rough manner, nor have they experienced a staff member speaking to residents in an inappropriate manner. UnsubstantiatedRead the full finding— CDSS inspection report, February 9, 2023 · control 56-AS-20230201162146

Licensing Program Analysts (LPA) Bernadette Allen made an unannounced visit to the facility for the purpose of initiating and delivering findings on the complaints above. LPA met with Keely Administrator who was informed of the purpose of my visit and the allegation above. Allegation #1 -Resident fell multiple times sustaining injuries LPA interview three (3) staff members who confirmed that resident 1 (R1) has fallen several times which has caused scars to (R1) legs and forehead. Based on record review and observations during LPA visit the resident has falling several times and sustained injuries while in care. Based on observation and record review as to allegation that the resident has fell multiple times and sustained injury is substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is being cited on the attached LIC 9099-D. SubstantiatedRead the full finding— CDSS inspection report, December 28, 2022 · control 56-AS-20221222140837

Licensing Program Analysts (LPA) Bernadette Allen made an unannounced visit to the facility for the purpose of initiating and delivering findings on the complaints above. LPA met with Keely Miller Administrator who was informed of the purpose of my visit and the allegations above. LPA conducted interviews and reviewed Resident (R1) file and at one point would feed themself without assistance. (R1) level of care has changed and has been feed by staff members to ensure that the resident is not deprived of food and liquids. LPA observed that the resident had been feed lunch and interviews conducted it was confirmed the resident is currently being feed and given water by staff members throughout the day. Based on the investigation, the above finding is Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. UnsubstantiatedRead the full finding— CDSS inspection report, December 28, 2022 · control 56-AS-20221222140837

Licensing Program Analyst (LPA), Yolanda Delgado arrived to the facility, unannounced, to conclude an investigation pertaining to the listed allegation. LPA identified herself and met with Krista Overymyer, Med Tech. LPA discussed the purpose of the visit and the elements of the allegation. It was reported that facility staff did not use proper lifting techniques, resulting in Resident’s arm being injured. It was stated that Resident #1 was pulled out of the bed utilizing a sheet and Resident’s arm, which caused the injury. LPA Delgado reviewed Resident #1’s care plan and it stated that staff were required to use a lift when assisting Resident #1. Information obtained from interviews, stated that staff members did not use the lift, as required for maximum assistance with all activities of daily living for Resident #1. It was advised that Staff #1 and Staff #2 were not trained in utilizing the Hoyer Lift, which was available. SubstantiatedRead the full finding— CDSS inspection report, February 18, 2022 · control 18-AS-20210322104401

Licensing Program Analyst (LPA), Yolanda Delgado arrived to the facility, unannounced, to conclude an investigation pertaining to the listed allegations. LPA identified herself and met with MedTech Krista Overmyer. LPA discussed the purpose of the visit and the elements of the allegations. It was reported to Community Care Licensing that Resident (R1) was injured at the facility, which required R1 to be transported and medically assessed. After the injury, facility staff contacted emergency services. X-rays on R1’s shoulder were taken. It was reported that R1 was required a cast. After interviews with staff and review of records, it was determined that R1 had to wear a splint, not a cast. Facility stated that the splint needed to be removed at times in order to be assessed for cleanliness and proper healing. It was not determined that the splint had to be removed with guidance from a physician. There were concerns that R1 was not being bathed regularly. Information obtained from staff,Read the full finding— CDSS inspection report, February 18, 2022 · control 18-AS-20210322104401

Licensing Program Analyst (LPA), Yolanda Delgado arrived to the facility, unannounced, to conclude an investigation pertaining to the listed allegations. LPA identified herself and met with Krista Overymyer, Med Tech. LPA discussed the purpose of the visit and the elements of the allegations. It was reported that staff were not meeting resident’s incontinence needs. It was stated that Resident (R1) had diaper burns. Information obtained from staff interviews stated that R1 would delay diaper changes or refuse to wear the diaper correctly. It was also reported that facility staff are not treating residents with dignity. It was reported that staff members yell and speaking inappropriately towards residents. Information obtained from interviews stated that staff are mean and rude to residents. Additional Interviews conducted with staff and residents revealed that staff do treat residents with dignity. It was also alleged that facility staff have violated resident's personal rights by notRead the full finding— CDSS inspection report, February 18, 2022 · control 18-AS-20210322104401