The Gardens

Allegation investigated: • Staff physically abused resident in care. • Staff verbally abused resident in care.

On 10/19/2023 LPA Tryon visited the facility to complete the complaint. LPA met with Brandy Strahl, ED and Jamie Scott. During the investigation LPA has spoken with witnesses, staff, reviewed documentation and reviewed and obtained police report. Regarding the allegation that Staff physically abused resident in care and verbally abused resident in care, LPA has spoken with witnesses, staff, reviewed documents, and staff statements. LPA learned that on 01/20/2023 former staff S1 was seen pulling resident R1 forward by their arms repeatedly in their chair at a meal and telling R1 they needed to sit up or S1 would not feed them. This was witnessed by at least 2 other staff members. In addition, staff S1 was seen pulling resident R2 backwards in their wheelchair. Resident was stating “stop” and that they were being hurt. S1 was also seen transporting resident R3 in their wheelchair with a belt buckled around them. Due to R3’s disability, They are unable to unfasten the seatbelt independently. Staff also witnessed S1 pulling R3 by the arm to get into the dining room. Substantiated The facility subsequently did an internal investigation into the above, followed facility personnel procedures, and took appropriate action. Although the facility took actions against S1, it has been found that S1 was physically and verbally abusive towards residents while employed at the facility. Based on interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. A finding of substantiated means that the preponderance of the evidence standard has been met. California Code of Regulations, Title 22, Division six and Chapter eight are being cited on the attached LIC 9099D. Regarding a resident physically assaulting another resident, staff reported observing a resident going towards another resident, however staff intervened, and no incident took place. There was talk of other residents being “assaulted” but LPA found no information about this, therefore cannot prove or disprove that any assaults actually occurred. Therefore, the allegation is unsubstantiated. Regarding staff not preventing residents from entering other residents’ rooms, LPA has spoken with staff, witnesses, etc. Based in interviews conducted, R1’s responsible party requested the R1’s bedroom door has the ability to be locked. It was reported that the door was unlocked the next day. It is not possible to say if the door was locked the previous night, who may have unlocked it, why, etc. The resident may have unlocked the door, which they certainly have the right to do. Staff are not able to constantly monitor the lock on one resident’s door to ascertain that it is always locked; and the resident has the right to lock or unlock their own door. The allegation is unsubstantiated. A finding that an allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 59-AS-20230530084440

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

(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: Through interview of staff and review of documentation, LPA learned that staff S1 repeatedly pulled resident R1 by the arms at the dining table and told her to sit forward or she would not feed her. She also fastened a seatbelt around R2 in her wheelchair when R2 could not unbuckle the belt; and pulled R2 backwards down the hallway, while R2 said to stop, it was hurting; and pulled R3 by the arms down the hallway. This potentially caused an immediate health and safety hazard.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: The facility immediately followed up regarding these incidents and investigated the situation. S1 was appropriately dealt with by the faciity. The facility also conducted Resident Rights training on DATE with staff to avoid similar situations in the future. POC complete.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Oct 17, 2023

(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: Through interview of staff and review of documentation, LPA learned that staff S1 repeatedly pulled resident R1 by the arms at the dining table and told her to sit forward or she would not feed her. This potentially caused an immediate health and safety hazard.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: The facility immediately followed up regarding these incidents and investigated the situation, followed facility procedures and took appropriate action. The facility also conducted Resident Rights training with staff to avoid similar situations in the future. POC complete.

Type of visit: Required - 1 Year

LPA HIratsuka, conducted this unannounced annual visit. LPA toured the facility with Nurse Manager Jamie Scott. This facility has a non-ambulatory fire clearance. This facility has a delayed egress system. This facility shares a campus with a skilled nursing facility and the backside of the property is The Courtyard 515000683. The parking lot has a wrought iron fence and gate that automatically opens. The common areas were toured and several rooms were toured. No health, safety, and personal rights issues were observed. Five resident files and staff training were reviewed during this visit. Several topics were discussed. No deficiencies cited.the state’s words, verbatim · CDSS document, Jul 31, 2023

Type of visit: Case Management - Incident

LPA Hiratsuka conducted this case management visit in response to two separate incidents reported by the facility. The first incident involved a resident who was found by the fire department just outside the property. This building has delayed egress. The facility administration did an investigation and they think the resident waited until a someone left the door and the resident ran out the door because the door does not lock right away. LPA asked if visitors are given the code to get and was told only facility staff are given the code. There is nothing in Title 22 regulations that require the code to be given to visitors and the facility is not. Health Services Director Jamie Scott stated all staff have been reminded to ensure the door is closed after anyone uses the door before walking away and signs have been posted. The second incident involves two residents: one who lives here and one who lives at The Courtyard, which is behind this building. The Courtyard is not a memory care facility. The resident who lives there had the one who lives here over as a guest and the resident who lives here was told to leave while over there and made it to a relative's house after being told to leave. The visitation rules for the resident who lives here has been adjusted to meet the resident's needs without violating the personal rights. No deficiencies citedthe state’s words, verbatim · CDSS document, Jul 13, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Mai Thao and Talwinder Bains arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain on today's date. LPAs met with Carol Pickard, Administrator and Jamie Scott, Nurse Manager. LPAs explained the purpose of the visit. Prior to initiating the annual inspection, LPAs 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. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 In addition, Staff screened LPA prior to entering the facility. The current census for today is 18. Areas toured include but are not limited to: common area, resident bedroom, bathrooms, dining room, and activity room. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs and Licensee completed the infection control domain during this inspection. At approximately 3:12pm, LPAs, Nurse Manager and Staff 1 (S1) reviewed 5 of 5 resident Centrally Stored Medication (CSM). LPAs, Nurse Manager, and Staff observed these CSM not entered in the Centrally Stored Medication Logs: Resident 1 (R1) has 7 CSM, Resident 2 (R2) has 1 CSM, Resident 3 (R3) has 5 CSM, and Resident 4 (R4) has 2 CSM. Administrator stated that facility has been without a nurse for a while and has not conducted audit on CSM to ensure that they are entered in CSM logs accurately. At approximately 5:01pm, LPAs, Administrator, and Nurse Manager observed Resident 5 (R5) without a sign admission agreement on file. 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 the deficiencies may result in civil penalties. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, May 17, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Mai Thao, arrived at the facility unannounced on 03/25/2022 to conduct a case management visit on an incident that was reported to Licensing on 3/23/2022 and met with Carol Pickard, Administrator. 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 they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask. A suspected abuse report was reported to Licensing on 3/23/2022 alleging that on 3/21/2022 Staff 1 (S1) hit Resident 1 (R1) and Staff 2 (S2) yelled at Resident (R1). During today's visit, LPA discussed the incident with Administrator, review documents, collected documents, and conducted interviews with Staff and Residents. Due to the lack of information at this time, follow-up may be needed at a later time. No citations were observed during this visit. Exit interview conducted and a copy of this report was left at the facility with Carol Pickard, Administrator.the state’s words, verbatim · CDSS document, Mar 25, 2022