Moldaw Family Residences at 899 Charleston

Allegation investigated: Staff handles residents in a rough manner

LPA Marrufo conducted an unannounced complaint investigation visit and met with Karen Lerner. On 05/10/2023, the Department received the complaint allegations and on 05/12/2023, LPA Marrufo conducted an initial complaint investigation visit. During visit on 05/12/2023, LPA Marrufo obtained copies of the following documents: resident R1 and R2’s Physician’s Report and Appraisal/Needs and Services Plan, Internal Incident Reports from staff S1-S5, Resident Roster, and Staff Roster. LPA Marrufo conducted interviews with staff S2, S6-S7, and attempted interviews with residents R1 and R2. LPA observed R1 and R2 during visit and conducted additional resident interviews. S1’s Internal Incident Report states that during the beginning of S1’s PM shift, S1 was doing rounds with S2 and S3. S1 stated that the residents were lying on top of their comforters, which made it hard for the staff to turn them during rounds. See LIC9099-C for more information. Page 1 of 2. Substantiated S2’s Internal Incident Report states while making rounds with S1, S1 began to pull R1’s comforter back while R1 was still on the bed. S2 described the way S1 pulled the comforter as “very rough.” S2 stated that S1 and S2 then went to R2’s bedroom. There, S1 began pulling on R2’s jeans while they were still buttoned on R2. S2 stated to have observed R2 to look as if R2 was in pain while S1 was pulling on R2’s jeans. S2 then told S1 that that was not the correct way to pull down the jeans but S1 ignored S2 and said the resident was fine. S2 then stayed with R2 to check on the resident and then reported the incidents to S2’s supervisor, S4. S3’s Internal Incident Report states that S1 grabbed R1’s blanket and tossed R1 over and yanked on R1’s pants to take them off. S3 states S1 then went to R2’s room and yanked on R2’s yellow blanket. Then, S1 yanked on R2’s pants without unbuttoning R2’s pants. S3 stated S2 told S1 to unbutton the pants because S1 was hurting R2. S4’s Internal Report states that S4 observed S1 pulling on R2’s jeans. During interviews, S1 stated that R1 and R2 were not properly placed on their draw sheets by the morning shift staff, so S1 did not attempt to turn over R1 and R2. S1 stated to have not pulled on R1 or R2's pants and that S2 already had denim pants pulled down R2's waist when S1 arrived. During interviews, S2 and S3 stated to have observed S1 pull on the blankets that R1 and R2 were resting on to turn them over. S2 and S3 stated to have observed S1 pulling on R1’s and R2’s pants to check them during rounds. S2 and S3 stated that S1 pulled on R2’s pants while they were still buttoned. Based on records review and interviews, there is preponderance of evidence to prove the alleged violation did occur. Therefore, the allegation is substantiated. See 9099-D for deficiencies cited per the California Code of Regulations, Title 22. This report was reviewed with Karen Lerner and a copy of the report and appela rights were provided. S3 stated during interview to have not observed any bruising on R1 or R2. S5’s written report from 05/09/2023 states that there is a “noted discoloration on left lower posterior leg” of R1. During interview, S5 stated to have not observed S1 when S1 was conducting rounds and checking on S1 and S2. Based on information from interviews conducted with staff, and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore the allegation is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22 This report was reviewed with Karen Lerner and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 18, 2023 · control 26-AS-20230510121329

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: May 19, 2023

87468.1(a)(3) Personal Rights: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Licensee did not ensure that staff S1 did not handle residents R1 and R2 in a rough manner by pulling on their blankets and pants, which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, May 18, 2023

Plan of correction: Licensee agrees to develop a plan to conduct in-service training for all direct care staff on proper protocols for turning residents in bed and checking on their soiled diapers and submit the plan to CCL by POC date. Once the in-service trainings are completed, Licensee agrees to submit copies of the in-service training logs to CCL. The logs should include names of staff trained, dates of training, training topic, and name and qualification of trainers.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Elyse Gerson and Assistant Executive Director Preet Kaur. During visit, LPA Marrufo toured the facility. The facility entrance had a visitor screening area. LPA Marrufo observed a 30-day supply of PPEs. LPA Marrufo observed a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. LPA Marrufo also observed emergency water supplies. LPA Marrufo observed the facility bathroom had available soap and paper towels. No deficiencies were cited at this time as per California Code of Regulations - Title 22. This report was reviewed with Assistant Executive Director Preet Kaur and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 27, 2022

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) David Marrufo conducted a quarterly non-compliance visit and met with Administrator Elyse Gerson and Assistant Executive Director Preet Kaur. LPA Marrufo reviewed the facility training logs that are part of the following facility non-compliance plan: 1. Licensee shall develop a plan in writing describing the training of facility staff on identifying and reporting residents’ change in conditions for timely appropriate medical attention. 2. Licensee shall develop a plan in writing describing the training of facility staff on observation and assessment of residents for any changes in physical, mental, emotional and social functioning to develop a plan of care to meet the resident’s needs. 3. Licensee shall develop a plan in writing describing training of facility staff on identifying prohibited and restricted health conditions and on submitting exception requests to the Department for residents with prohibited or restricted health conditions. Staff should be trained on when to retain a resident, when to request an exception request for the resident, and when to seek a higher level of care for the resident. 4. Licensing shall develop a plan in writing describing the facility protocol when readmitting residents to the facility from the hospital or skilled nursing facility. The plan should include re-appraisals of the resident and developing a new plan of care to meet the resident's needs. 5. Licensee shall develop a plan in writing describing how the personal rights of residents are not violated when resident exhibits wandering behavior, particularly for residents diagnosed with dementia. 6. Licensee shall develop a plan in writing describing the facility protocol to collaborate with other agencies such as hospice agencies and home health agencies to ensure that doctors' orders in the care of the resident are met. 7. Licensee shall develop a plan in writing describing the duties and responsibilities of the Administrator to ensure that resident's health conditions and needs area addressed. The plan shall include staff meetings to communicate resident health conditions and needs. See LIC809-C for more information. Page 1 of 2. LPA Marrufo observed training for the non-compliance plans were conducted on 08/16/2022, 08/30/2022, 10/11/2022, and 10/13/2022. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Assistant Executive Director Preet Kaur and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 27, 2022

Allegation investigated: Facility did not ensure changes in resident's condition were reported to a physician and responsible party. Facility did not have an exception to retain a resident with a catheter. Facility neglience resulted in resident sustaining serious bodily injury

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit to deliver the findings on the above allegations and met with Preet Kaur, Associate Executive Director. On 01/17/2020, the Department conducted an initial complaint investigation visit regarding the above allegations and obtained copies of documents related to the complaint investigation. Between 1/22/20 and 5/28/2020, the Department conducted interviews and review of documents and made another facility visit on 07/22/2021. 9 facility staff, 1 family member, 2 agency staff and resident (R1) were interviewed. R1 was unable to communicate and did not respond to questions. 9 out of 9 facility staff stated there was no incident report done or concern of blood in urine brought to the attention of home health agency or primary doctor or family member. 2 out of 2 agency staff stated they were not informed of any concern of possible blood in urine. Substantiated The review of End of Day reports dated 12/26/2019 through 1/3/2020 noted on 12/26/2019, 12/29/2019, 12/30/2019, 01/01/2020, 01/02/2020, and 01/03/2020, multiple staff noticed blood in R1’s urine. On 01/03/2020, facility staff S1 noticed a discharge coming from R1’s penis and reported the concern to the nurse on duty, S2. S2 stated during interview to have told S1 to “keep an eye on it.” S2 stated to have forgotten to have made a report on the incident to S2’s supervisor before leaving work. On 01/04/2020, R1 had a fever and on 01/05/2020, when R1 stood up, blood, pus, and urine “gushed onto the floor.” R1 was taken to the hospital by the family member on 1/5/2020 and was hospitalized. R1 was diagnosed with traumatic hypospadias with fibrinous exudate at the meatus. Facility staff were unable to provide any evidence that R1’s condition was reported to attending Home Health agency or primary care physician. R1’s Physician’s Report and Appraisal/Needs and Services Plan indicate that R1 had been given a primary diagnosis of dementia. On 12/16/2019, the hospital discharged R1 to the facility with a catheter and discharge indicating arrangement with Home Health Agency for catheter care assistance once a week. In an email sent to the Department on 03/30/2022, staff S4 stated that the facility had no record of submitting an exception request for R1’s catheter. The Department did not receive any exception request on the restricted health condition for R1’s use of a foley catheter. Facility did not have a plan of care to address the resident’s pulling of the catheter which resulted in injury, infection, and hospitalization. Based on records review, interviews with staff and witnesses, and observations, there is preponderance of evidence to prove the alleged violations did occur; therefore, the allegations are substantiated. An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in serious injury to a resident in care. An additional Civil Penalty in the amount of $10,000.00 for violation Resulting in Serious Bodily Injury is pending review. Deficiencies were cited today under the California Code of Regulations, Title 22, Division 6. Please see LIC 9099-D. Report was discussed with Assistant Executive Director Preet Kaur. A copy of this report and licensee’s Appeal Rights forms were provided. Appeals must be directed to Licensing Regional Manager.the state’s words, verbatim · CDSS document, Aug 12, 2022 · control 26-AS-20200115090530

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87613(c) · Plan of correction due date: Aug 13, 2022

General Requirements for Restricted Health Conditions (c) The licensee shall document any significant occurrences that result in changes in the resident’s physical, mental and/or functional capabilities and immediately report these changes to the resident’s physician and authorized representative. This requirement was not met as evidenced by: facility staff failed to immediately report the changes to R1’s physical condition of possible blood in urine to R1’s physician/home health and authorized representative. Staff observed blood in urine as early as 12/29/19 but facility did not report until 1/5/2020 when authorized representative noticed the change during visit which resulted in serious bodily injury to R1.the state’s words, verbatim · CDSS document, Aug 12, 2022

Plan of correction: Licensee agrees to submit a plan to CCL by POC date to retrain facility staff on identifying and reporting residents’ change in conditions for timely appropriate medical attention for residents. Licensee shall submit the plan to CCL by POC date and once training is completed, submit copies of training rosters with names of staff trained, names and certifications of trainers, and dates.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Aug 13, 2022

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: Facility staff failed to bring to the attention of R1’s physician and family representative when staff observed R1 had a penile discharge from 12/29/19 through 01/3/2020, which posed a serious health risk to residents in care.the state’s words, verbatim · CDSS document, Aug 12, 2022

Plan of correction: Licensee agrees to retrain facility staff on observing and reporting resident’s change in condition to resident representatives, including resident physician/home health and family members. Licensee shall submit the plan to CCL by POC date and once training is completed, submit copies of training rosters with names of staff trained, names and certifications of trainers, and dates.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87616(a) · Plan of correction due date: Aug 13, 2022

87616(a) Exceptions for Health Conditions: As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means. This requirement was not met as evidenced by: the licensee did not submit an exception request for R1’s Foley catheter, which posed a serious health risk to residents in care.the state’s words, verbatim · CDSS document, Aug 12, 2022

Plan of correction: Licensee agrees to retrain facility staff on identifying prohibited and restricted health conditions and on submitting exception requests to the Department for residents with prohibited or restricted health conditions. Licensee shall submit the plan to CCL by POC date and once training is completed, submit copies of training rosters with names of staff trained, names and certifications of trainers, and dates.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Preet Kaur, Associate Executive Director. The purpose of the visit was to issue citations for deficiencies that were found to have occurred during a complaint investigation but were not included as part of the original allegations. Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D for more information. This report was reviewed with Preet Kaur and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 12, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87609(b)(4) · Plan of correction due date: Aug 19, 2022

87609(b)(4) Allowable Health Conditions and the Use of Home Health Agencies The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s). This requirement was not met as evidenced by: Licensee did not ensure that a written agreement was made between the facility and R1’s home health agency regarding the responsibilities of the home health agency for R1, which posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Aug 12, 2022

Plan of correction: Licensee agrees to conduct training for relevant staff to obtain written agreements with home health agencies on the responsibilities of home health agencies for residents in care by POC date. Once training is completed, the Licensee agrees to submit copies of the training including date of training, names of staff trained, and name and qualifications of trainer to CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a)(3) · Plan of correction due date: Aug 19, 2022

87463(a)(3) Reappraisals: 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. This requirement was not met as evidenced by: Licensee did not ensure that R1’s appraisal needs and services plan was updated to address R1’s catheter care plan, which posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Aug 12, 2022

Plan of correction: Licensee agrees to conduct training for relevant staff to update residents written reappraisals whenever residents experience a significant change in condition by POC date. Once training is completed, the Licensee agrees to submit copies of the training including date of training, names of staff trained, and name and qualifications of trainer to CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Aug 19, 2022

87211 (a)(1)(B) Reporting Requirements 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. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement was not met as evidenced by: Licensee did not ensure that a written report was submitted to CCLD about R1’s urine containing blood, which posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Aug 12, 2022

Plan of correction: Licensee agrees to conduct training for relevant staff to submit written reports to CCLD regarding any serious injuries to residents by POC date. Once training is completed, the Licensee agrees to submit copies of the training including date of training, names of staff trained, and name and qualifications of trainer to CCLD.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced annual Required 1 Year visit and met with Karen Lerner. During visit, LPA Marrufo toured the facility. The facility entrance had a visitor screening area. LPA observed the facility bathroom had signs related to COVID-19 and hand washing guidelines. LPA Marrufo observed the facility PPE supply and found the facility had a PPE supply of at least 30-days. LPA Marrufo observed the common areas in the Assisted Living and Memory Support sections of the facility and observed there to be socially distanced seating and COVID-19 related signs posted. LPA Marrufo observed the dinning areas in the Assisted Living and Memory Support areas. LPA Marrufo observed the facility kitchen and found there to be a perishable food supply of at least 3 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed facility staff to be wearing face coverings. No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Karen Lerner and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 22, 2021

Type of visit: Case Management - Other

Licensing Program Manager (LPM) Jackie Jin, Licensing Program Analyst (LPA) David Marrufo, and Nurse Cristina Wong conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility and met with Administrator Elyse Gerson and Wellness Director Gabriella Brigham. The Administrator reports that there are currently 8 COVID-19 positive residents and 4 COVID-19 positive staff. During today's tele-visit, the following recommendations were made to the facility by Nurse Cristina Wong: 1. Remind staff to label cleaning spray bottles with expiration dates 2. Ensure no more than 2 households in an elevator at a time 3. Continue training staff regarding donning and doffing of PPEs 4. Continue training staff regarding wiping down surfaces No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed with Wellness Director Gabriella Brigham. A copy of the report will be sent to her for it to be signed and returned to CCL.the state’s words, verbatim · CDSS document, Sep 3, 2021