Brookdale Kettleman Lane

Type of visit: Case Management - Deficiencies

On 10/26/2023 Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a case management visit to follow up on an incident report submitted to the Department. LPA was allowed entry into the facility, met with the executive director, and explained the purpose of today’s visit. During the course of the department’s investigation, Interviews were conducted, and records reviewed. Interviews and records review conclude, The Licensee failed to ensure a sufficient provision to aid in fall prevention of R1 after R1 sustained multiple falls over a seven month period which led to injury of R1. On October 19th, 2023, the Department concluded the investigation and substantiated the findings. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 25, 2023

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Oct 30, 2023

Basic Service Requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement was not met as evidenced by: Based on record reviews and interviews, R1 sustained multiple falls over a period of seven month time frame without the Licensee ensuring appropriate intervention to aid in R1’s care and supervision resulting in injury. This posed an immediate risk to residents health, safety, and resident rights.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Facility Administrator agrees to develop a plan and conduct training for all staff by POC date 10/30/2023 on appropriate intervention to aid in care and supervision to prevent injury. Facility will email LPa the signed sheet of training compleated by 11/10/2023. Kesha.lewis@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR87463(a)(3) · Plan of correction due date: Oct 27, 2023

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:(3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. Based on records review there was no updated needs and services plane done for R1 after falling multiple times. This posed an immediate risk to residents health, safety, and resident rights.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Licensee shall provide a statement of acknowledgement that appraisals are conducted on an ongoing basis by the POC date. Kesha.lewis@dss.ca.gov

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced Annual 1-Year Required visit on this date. LPA met and toured with Administrator Nicole Pleasette Bacon. The administrator currently holds a certificate (#6044139740). LPA toured the facility that consists of 30 total bedrooms of which 30 bedrooms can be occupied by the residents and zero bedrooms are occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured at 105 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. The last fire drill occurred on 03/30/23. Fire extinguisher was last serviced on 10/12/2022. Emergency Disaster Plan was last updated on 05/29/2023. First aid kit was observed to be complete. LPA reviewed staff record files and the facility has sufficient staffing to provide the services needed to meet the residents’ needs. All staff have criminal record clearance and are associated to the facility. All staff have current first aid training. The facility serves residents with dementia and staff have received the necessary training hours specific to dementia. LPA reviewed 4 of 43 residents’ files. There were 4 of 50 files reviewed for staff but due to technical difficulties, LPA was unable to record the results of the staff file review. No deficiencies were cited during this inspection. Exit interview conducted. Report provided.the state’s words, verbatim · CDSS document, May 30, 2023

Allegation investigated: Staff denied resident phone access Staff denied resident visitors

On 04/28/2023 at approximately 8:30 am, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to deliver complaint findings for the allegations noted above. LPA met with Mary Margaret Chappell, Executive Director, and explained the purpose of the visit. Based on Department interviews and record reviews, it was determined that resident1 (R1) had been placed under Conservatorship with San Joaquin County Public Guardian's Office after breaking her hip . R1 was then sent to the facility from the hospital. Initially, R1 had been able to call people and have visitors per witnesses and the complainant according to facility rules. This was changed by the Conservator, not the facility. R1 was barred from having visitors or making phone calls at the Conservators request. Therefore, based on department record review, we have found that the complaint was unsubstantiated, meaning, 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, Exit interview completed and a copy of report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 28, 2023 · control 27-AS-20230306110047

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.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Renee Campbell arrived to the facility unannounced on 03/14/23 at approximately 11:00 am to conduct case management visit to follow up on various incident reports received. LPA met with Business Manager, Patricia Olvera and Associate Executive Director Nicole Bacon and explained the purpose of the visit. LPA reviewed documents and verified proper protocols were followed. The following residents received immediate medical care and their respective responsible parties were notified. Resident (R1) had an unwitnessed fall, experienced vaginal bleeding and was taken to the hospital for tests and released with no new discharge orders. No diagnosis was found. Residents 2 to Resident 13 (R2 to R13) experienced nausea and vomiting and had to go to the hospital to receive medical care. Per the Business Manager, two residents tested positive for Norovirus but by that time, the rest of the residents had recovered. All residents returned to baseline and remain in care at the facility. Resident 13 (R13) experienced edema. He refused transport to the hospital until his daughter arrived and drove him herself. He also returned to the facility. Business Manager, Patricia Olvera and Associate Executive Director Nicole Bacon agreed to provide supporting documents by 03/15/23 at the latest. Exit Interview and copy of report provided.the state’s words, verbatim · CDSS document, Mar 14, 2023

Type of visit: Case Management - Incident

On 3-1-23 at 1:35pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding incidents which occurred on 1-9-23 and 1-10-23. LPA met with Health and Wellness Director Gretchen Monares and explained the purpose of the visit. LPA reviewed incident reports dated 1-15-23 and facility file documentation for resident1 (R1) and R2. LPA also conducted health and safety facility tour as part of this case management. Additionally, LPA interviewed Health and Wellness Director On 1-15-23, facility reported that on 1-9-23, R1 was not assisted with administering medication Methadone 5mg (milligram) as prescribed by Physician. Medication orders reviewed confirmed medication was prescribed with start date of 11-17-22. On 1-15-23, facility reported that on 1-10-23, R2 was not assisted with administering medication Depakote 250mg (milligram) as prescribed by Physician. Medication orders reviewed confirmed Physician orders for medication are dated as of 6/30/22. LPA conducted facility tour with health and wellness director. LPA observed facility common areas, various resident rooms, kitchen area and hallways. Facility was observed by LPA to be clean and sanitary. Floors and walls were clean without prominent stains. Facility was observed to contain no foul odors. Food supply was adequate with 7 days of non-perishables and 2 days of perishable items in place. Staffing levels included 2 med techs, 3 caregivers, 3 kitchen staff, 4 management staff, and 1 receptionist. Fire extinguisher was full charged and dated 10-12-22. Room temperature was 71*F. Facility is a secured, exclusive memory care unit. Egress door alarms are placed on doors and functioning properly. There is a lobby area leading to a secured, alarmed door leading to memory care unit. Smoke alarms and carbon detectors are functioning properly. Current census is 39. No obstructions to fire exits noted during today's tour. As a result of today's case management visit, deficiencies are cited under Title 22, Division 6, Chapter 8. A civil penalty in the amount of $250 is issued in addition to citation due to repeat violation within 12-month period. An exit interview was conducted with Gretchen Monares and a copy of this report was left with Gretchen. Appeal rights provided.the state’s words, verbatim · CDSS document, Mar 1, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 1, 2023

Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interview and record review,Licensee did not comply with section cited above in that R1 and R2 did not receive medication as prescribed by physician due to facility staff error. This posed an immediate health and safety risk ti residents in care.the state’s words, verbatim · CDSS document, Mar 1, 2023

Plan of correction: Licensee will ensure completed staff training on proper assistance with self-administration of medication including but not limited to: Following physician orders. Training date to be submitted to LPA by POC due date. Training to be completed no later than 2 weeks from date of citation issuance. Proof of completed training to be submitted to LPA prior to citation clearance.

Type of visit: Case Management - Incident

On 01/17/23, Licensed Program Analysts (LPA'S) Kesha Lewis and Albert Johnson arrived at Brookdale Kettlemen at approximately 12:50 pm to conduct a case management visit regarding an incident submitted to CCLD on 11/25/22, 11/ 27/22, 12/ 07/22. LPA'S spoke with administer and explained the purpose of the visit. Based on incident report received 11/25/2022, R1 was found in their room with a white substance on their lips it was later determined that the white was sunscreen, resident was unable to say whether the substance was ingested. Based on R1's 602 it was determined that they would be at risk if allowed direct access to personal grooming products. Based on incident report on 11/23/22, R2 was breathing heavily and clearing their throat, they were sent to the ER and released later. Based on R2's 602 it was determined that she would be at risk if allowed direct access to personal grooming products. Based on incident report received 12/07/2022 R3 was complaining of severe pain in their right hip after a fall that occurred on 12/06/22. Based on R3'S needs and service plan they are at higher rick for fall. During records review it was found that R4 had a fall with injury. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview with Executive Director. Appeal rights and a copy of report was given.the state’s words, verbatim · CDSS document, Jan 17, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(g)(1) · Plan of correction due date: Jan 18, 2023

87705(g)(1) Care of Persons with Dementia. (g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. (1)Evidence means documentation from the resident’s physician that the resident is at risk if allowed direct access to personal grooming and hygiene items. This requirement is not met as evidenced by: Based on records review The licensee did not ensure that staff met the care and supervision needs of R1 and R2 who had access to toxins in the facility when their 602 stated they would be at risk if allowed direct access to personal grooming products. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 17, 2023

Plan of correction: Licensee agrees to submit a written plan ensuring that staff met the care and supervision needs of residents with Dementia. Plan of Correction is due on 01/18/2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR87457(c)(1) · Plan of correction due date: Jan 27, 2023

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors. This requirement is not met as evidenced by: Based on records review R3 and R4 had missing pre appraisal which did not allow facility or LPA'S to determine residents needs upon arrival. This poses an potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 17, 2023

Plan of correction: Licensee agrees to submit a written plan ensuring that staff met the care and supervision needs of residents with Dementia. Plan of Correction is due on 01/27/2023

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Kesha Lewis and Albert Johnson conducted a case management visit as a result of the incident that took place on November 8, 2022. LPA met with the facilities Administrator and explained the purpose of today's visit. The department received an incident report detailing that R1 was given an extra dose of Seroquel 25mg this was a PRN medication and was not listed on the Admissions Orders dated 3/10/22 which contains the PRN information with instructions from R1’s primary care physician. LPAs were unable to review a current PRN letter for R1, because the facility did not have a current PRN letter for R1. During the file review of R1, LPA'S observed that R1 was being treated for rash that was later identified as scabies, (SIR) Special Incident Report was not sent to CCL until 10/04/2022. Rash first identified on June 30, 2022 treatment was given, however unsuccessful and on 8/15/2022 the facility contacted R1's primary physician and started treatment for the rash again. This was also unsuccessful. On 9/28/222 the facility took R1 to urgent care and was given the diagnoses of Scabies. The facility then reported to the Department on 10/4/22 LPA obtained information from R1'S file. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. Exit interview and copy of report provided, appeal rights given.the state’s words, verbatim · CDSS document, Nov 21, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Nov 22, 2022

87465(c)(2) Once ordered by the physician, nonprescription PRN medications shall be given in accordance with the physician’s directions. This requirement was not meet as evidenced by. LPA Received SIR for R1 being given an extra dose of medication.the state’s words, verbatim · CDSS document, Nov 21, 2022

Plan of correction: By 11/22/2022 the Administrator shall evaluate the facility's medication distribution practices and submit a revised program plan on medication management to avoid any further medication errors. Further, additional medication training shall be completed by staff who handle medication.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(d)(1-3) · Plan of correction due date: Nov 22, 2022

If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Records reviewed and interviews with the Administrator confirmed that the facility did not have the Physician identify the abilities of R1 to determine her needs for PRN medication as a result the facility administered Seroquel twice as a PRN which was not how the PRN was written. The facility does not have a current list of PRN medications sign by the Physician as to R1’s ability to determine if the medications are needed and whether are not the Physician needed to be contacted prior to or afterthe state’s words, verbatim · CDSS document, Nov 21, 2022

Plan of correction: Licensee shall submit plan on when an in-service to medication staff will be completed. Completion shall be submitted with proof of attendance to CCL by 11/22/22, as well as updating the resident files to include a signed PRN letter for each resident that takes a PRN with the wishes of the assigning Physician

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(d) · Plan of correction due date: Dec 3, 2022

Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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 in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not meet as evidenced by records review LPA'S reviewed R1'S file and found they were being treated for rash that was later identified as scabies, (SIR) serious incident report was not sent to CCL until 10/04/2022. Rash first identified in June 30th 2022. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 21, 2022

Plan of correction: Administrator will review Title 22 Regulations Section 87211 and have an In-service training with all Staff regarding Reporting Requirements. Administrator will submit a written plan ensuring that incidents are reported to the CCL office as required according to the Regulation. Signatures of all Staff from the training must be submitted to CCL after training is complete. The plan is due by the POC date of 12/03/22.

Type of visit: Case Management - Other

Licensed Program Analyst (LPA) R. Campbell conducted a case management visit to this facility on 10/12/22 at approximately 4:00 pm to follow up on an incident report submitted from the facility on 07/15/22. LPA met with Mary Margaret Chappell On 07/09/22, R1 had an unwitnessed fall in the activities room. When staff arrived, he was found laying on the floor. R1 had a small laceration to the right side back of his head. Before calling 911, staff called R1’s responsible party who notified staff he would drive R1 to the hospital. The responsible party arrived a few minutes later to transport R1 to the local hospital. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview with Executive Director. Appeal rights and a copy of report given.the state’s words, verbatim · CDSS document, Oct 12, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(g) · Plan of correction due date: Oct 26, 2022

87465(g)Incidental Medical and Dental. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health ... This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not call 911 as required by requlations.the state’s words, verbatim · CDSS document, Oct 12, 2022

Plan of correction: Licensee will provide staff training on 911 policy and provide proof of training to LPA by POC date.

Type of visit: Case Management - Other

On 10/12/22, Licensed Program Analyst (LPA) R. Campbell arrived at Brookdale Kettlemen at approximately 1:00 pm to conduct a case management visit regarding an incident submitted to CCLD on 07/17/22. LPA spoke with Med Tech Delma De la Pena and explained the purpose of the visit. Based on incident report, Med Tech #1(M1) reported that a medication error occurred on 07/17/22 . During change of shift, M1 was counting narcotics and realized Resident #1(R1) had not been given a full dose. R1 was to receive a 7.5mg of Methadone orally at 9 am but instead was only given 5 mg. R1 did not have any signs of distress or complaints of pain. R1's physician and family members were made aware of incident. Also on 08/15/22 facility reported that Resident #2 (R2) missed her dosage of Ativan and Tramadol as well and a dose of Tramadol 50 mg was missing for Resident #3(R3) . Based on a review of R1’s incident that occurred on 07/17/22, R2’s incident report from 08/15/22, R3's incident report from 08/20/22 and their Medication Logs, medication was not provided or was provided incorrectly in error. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview with Executive Director. Appeal rights and a copy of report was given.the state’s words, verbatim · CDSS document, Oct 12, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 24, 2022

87465(a)(4)Incidental Medical and Dental Care …The plan shall encourage routine medical and dental care … (4) The licensee shall assist residents with self-administered medications .... This requirement is not met as evidenced by Based on observation, interview and record review, medication was missed on 08/15/22 and given incorrectly on 07/17/22 and 08/20/22 which poses a potential Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 12, 2022

Plan of correction: Licensee will require that med-techs undergo training on following medication orders. Licensee will provide proof of training by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) R. Campbell and T. White conducted an unannounced Annual 1-Year Required visit on this date. LPAs met and toured with Executive Director Sara Mackedsy. The facility’s fire clearance was approved for 04/2014. Upon entry LPA was screened for COVID symptoms, a sign in/sign out procedure was observed as well as facility staff wearing masks. LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 106 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. The last fire drill occurred on 06/26/2022. Fire extinguisher was last serviced on October 26, 2021. First aid kit was observed to be complete. LPA reviewed 5 out of 5 staff files and the facility has sufficient staffing to provide the services needed to meet the residents’ needs. 5 of 5 staff have current first aid training but signed employee rights were not found in employee files. One staff did not have a health screening. The facility serves residents with dementia and staff have received the necessary training hours specific to dementia. LPA reviewed 5 of 5 residents’ files and a sample of residents’ medication logs were reviewed. LPAs observed the following deficiency: - During record review, LPAs observed 1 of 5 staff not associated to the facility. - During record review, LPAs observed no signed employee rights forms in 5 of 5 staff personnel file. -During record review, 1 out of the 5 staff did not have a health screening. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 ,and California Health and Safety Code. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 5, 2022

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Jul 19, 2022

(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This regulation was not followed as observed in the lack of sighed Employee RIghts forms in Personnel Files. Based on record review, licensee did not comply with section cited above in 87412(g). LPA observed 5 of 5 staff files did not have employee rights on file which poses as a potential health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Jul 5, 2022

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Jul 6, 2022

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance. This requirement was not met as evidence by:the state’s words, verbatim · CDSS document, Jul 5, 2022

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Jul 6, 2022

Based on record review, licensee did not comply with section cited above in 87355 (e)(2). LPA observed S1 is not associated to the facility which poses as an immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Jul 5, 2022

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On 06/06/2022, Licensing Program Analyst (LPA) T. White conducted case management visit regarding incident submitted to CCLD on 04/05/2022. LPA spoke with Health and Wellness Director, Gretchen Monares and explained the purpose of the visit. Based on incident report, Staff #1 (S1) reported that a medication error had occurred on 04/05/2022. Staff #2 (S2) was counting narcotics/anti-biotics for end of shift when S2 told Staff #3 (S3) she had not given Resident #1 (R1) dose of Linezolide. S2 failed to look at the antibiotic count shet and proceeded to give R1 a dose of Linezolide. As S2 proceeded to sign out the medication in the count sheet, he noted S1 had already signed out dose to R1. Based on incident report, R1 received 2 doses of Linezolide. R1 did not have any signs of distress or complaints of pain. R1's physican and family members was made aware of incident. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview with Health and Wellness Director. Appeal rights and a copy of report given.the state’s words, verbatim · CDSS document, Jun 6, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jun 7, 2022

87465(c)(2): Incidental Medical and Dental Care:(c) ...provided all of the following requirements are met:(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidence by: Based on documentation, Facility did not comply with the section cited in 87465(c)(2). Based on documentation, there was a medication error with R1, resulting in R1 receiving medication twice. This poses an immediate health and safety risks to clients in care.the state’s words, verbatim · CDSS document, Jun 6, 2022

Plan of correction: Facility agreed to conduct in-service training regarding medication order with all staff and submit proof to CCLD by POC date. Deficiency cleared during inspection.

Type of visit: Case Management - Incident

On 02/16/2022, Licensing Program Analyst (LPA) T. White conducted case management visit regarding incident submitted to CCLD on 01/29/2022. LPA spoke with Executive Director(ED), Mary Margaret Chappell and explained the purpose of the visit. Based on incident report, Staff #1 (S1) reported that a medication error had occurred on 01/24/2022. Methadone 2.5mg was due to be administered at 10:00PM and was administered in error at 8:00PM by Staff #2 (S2) after medication time was changed to 10:00PM resulting in the medication being administered twice. Based on documentation and interview, R1's primary care physician, Vitas hopsice agency, and R1's family member was notified on 01/24/2022. No adverse reaction or increased pain noted. Based on Staff #3 (S3), S2 was moved from Med Tech to care staff until additional medication training was completed. S3 stated, S2 no longer works at the facility. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview with Executive Director. Appeal rights and a copy of report given.the state’s words, verbatim · CDSS document, Feb 16, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Feb 24, 2022

87465(c)(2): Incidental Medical and Dental Care:(c) ...provided all of the following requirements are met:(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidence by: Based on documentation, Facility did not comply with the section cited in 87465(c)(2). Based on documentation, there was a medication error with R1, resulting in R1 receiving medication twice. This poses a potential health and safety risks to clients in care.the state’s words, verbatim · CDSS document, Feb 16, 2022

Plan of correction: ED agreed to conduct in-service training regarding medication order with all staff and submit proof to CCLD by POC date.

Type of visit: Case Management - Incident

LPA's T. White and M. Jensen arrived at this facility unannounced on 01/25/2022 at 12:30 PM to conduct a case management visit. LPA's T. White and M. Jensen met with Executive Director Mary Margaret Chapell and explained the purpose of the visit. The purpose of the visit is to follow up on an incident report received on 12/29/2022. The report stated on 12/19/2022 at 2:30 PM, R1 walked up to R2 and pushed her. R2 became defensive and hit her back with an open hand causing a small scratch to R1's left side of face. R1 and R2 were separated and directed away from each other. LPA's interviewed two staff members and reviewed R1 and R2's file documentation. Based upon interviews conducted on 01/25/2022 and facility records, the client has a history of aggressive behavior. LPA's discussed facility plan to prevent and mitigate further acts of aggression and plan proposed was appropriate. LPA's determined there has been no further incidents of concern to date. Based on documentation, facility failed to meet the 7 day reporting requirement for Special incident reports. The incident occurred on 12/19/21 and the facility submitted the special incident report on 12/29/21. The following deficiency was observed and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalty. Exit interview conducted and appeal rights given.the state’s words, verbatim · CDSS document, Jan 25, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Feb 1, 2022

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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 in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidence by based on observation facility did not comply with the section cited above in 87211(a)(1). LPA observed facility did not inform CCLD within 7 days of incident occurrence which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 25, 2022

Plan of correction: Executive Director agreed to review regulations on reporting requirements. Executive Director also agreed to conduct in-service training with management and submit proof to CCL by POC date.

Type of visit: Case Management - Incident

On 09/30/2021, Licensing Program Analyst (LPA) T. White conducted case management visit regarding COVID positive resident. LPA spoke with Executive Director(ED), Mary Margaret Chappell and explained the purpose of the visit. Based on information provided, Local Department of Public Health (LDPH) was informed that Resident #1 (R1) was COVID positive on 09/27/2021. Based on observation and interview, ED did not inform CCLD within 24 hours that R1 tested positive for COVID. ED stated there is currently no additional COVID cases at this time. ED stated she will submit incident report to CCLD by 09/30/2021 end of day. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview with Executive Director. Appeal rights and a copy of report given.the state’s words, verbatim · CDSS document, Sep 30, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(2) · Plan of correction due date: Oct 4, 2021

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following (2)Occurrences, such as epidemic outbreaks... shall be reported within 24 hours either by telephone or facsimile to the licensing agency... This requirement is not met as evidence by. Based on LPA observation, facility did not comply with section cited above on 87211(a)(2). LPA observed facility did not inform CCLD of COVID positive resident within 24 hours which poses as an immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Executive Director agreed to review regulations on reporting requirements. Executive Director also agreed to conduct in-service training with management and submit proof to CCL by POC date.

Allegation investigated: Facility staff are forging residents' medical assessments.

On 08/04/2021, Licensing Program Analyst (LPA) T. White conducted an unannounced complaint investigation regarding the above allegation. LPA White discussed the purpose of the visit and the elements of the allegation with Executive Director, Mary Margaret Chappell. During the course of investigation, LPA collected medical assessments (LIC602) and Emergency Contact Information for 10 residents. LPA conducted interviews with 2 staff members and 3 of resident's responsible party's'. Based on staff interviews, S1 stated each Doctor's office has different procedures to completing residents medical assessments. S1 stated the facility, family, or medical assistant will fill out residents medical assessment. S1 stated the Doctor will review the filled out portion, review the document and sign. S1 stated the Doctor completes the diagnosis and medications on the medical assessment. Staff #2 (S2) stated the facility never touches documents after it is signed by the Doctor. Report continues on 9099C. Unsubstantiated LPA interviewed 3 of 10 residents responsible party. Based on interviews, R1's responsible party stated the she fills out the first page and the Physician fills out the remaining pages of R1's medical assessment. R2's responsible party stated the facility fills out the medical assessment and gives it to the Physician to sign. Based on interviews and documentation, there is insufficient information to determine the facility staff are forging residents' medical assessments. Based on information obtained, LPA determined these allegations to be UNSUBSTANTIATED- means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. There are no citations being issued today. Exit interview conducted with Executive Director and a copy of report given.the state’s words, verbatim · CDSS document, Aug 4, 2021 · control 27-AS-20210715114811

Type of visit: Required - 1 Year

On 07/20/2021 at 8:35am, Licensing Program Analyst (LPA) T. White spoke with facility staff, regarding facility risk assessment questions. Facility staff confirmed no staff or clients have experienced symptoms within the last 10 days. At 9:50am, LPA T. White arrived unannounced to conduct a required 1-year annual inspection. LPA met with Executive Director, Mary Margaret Chappell and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 56 non-ambulatory residents which 15 may be on hospice. LPA toured the facility including but not limited to apartments, bathrooms, kitchen, common area, backyard and courtyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathrooms was measured at 109.9, 107.2 and 106.2 degrees Fahrenheit. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. LPA observed smoke detector is interconnected with the fire department. LPA observed carbon monoxide was in operating condition during inspection. Fire extinguisher was last serviced on October 28, 2020. Emergency Disaster Plan was last posted on 06/22/2021. First aid kit was observed to be complete. Fire drill was last conducted on 07/04/2021. LPA observed mitigation plan is complete. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 07/27/2021: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan No deficiencies cited. Exit interview conducted with Executive Director and a copy of report given.the state’s words, verbatim · CDSS document, Jul 20, 2021