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Allegation investigated: Resident sustained injuries while in care

This is an amendment to an original 9099 dated 2/21/2023 On 03/20/23 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with administrator (ADM) to amend the finding of above allegation due to additional information received. LPA explained the purpose of the visit with ADM. Allegation: Resident sustained injuries while in care Investigation Finding: Unsubstantiated On 02/24/23, the Department interviewed the staff (ADM, W1) who confirmed that resident (R1) was taken to the hospital on 05/16/21 due to an altered level of consciousness and suspected possible seizure. The Department reviewed R1’s hospital records dated 5/16/21 thru 5/22/21 which showed R1 had no pressure injuries noted upon admission. While at the hospital on 05/18/21, ER nurse reported unstageable pressure injuries found on R1’s leg and ankle with a primary diagnosis of pulmonary embolism. The Department interviewed staff (ADM, W1) on 02/24/23 who confirmed with LPA that R1 developed the pressure injuries while in care at the hospital on 05/18/21. Based on records review, interviews conducted and observations made, the Department has investigated the above allegation and found that it is unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation that resident sustained injuries while in care did occur. Exit interview conducted and a copy of this report provided. Unsubstantiated While at the hospital and upon presentation, ER nurse also reported unstageable pressure injuries found on R1’s leg and ankle. Detailed wound care instructions, a home health (wound care) referral and a set of moon booties were sent with R1 to the facility. Wound care nurse visits were scheduled weekly at the facility and the wounds mostly healed. The preponderance of evidence has been met. Therefore, the allegation that resident sustained injuries while in care is substantiated. Immediate civil penalty of $500 is being assessed on today’s visit. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Feb 21, 2023 · control 15-AS-20210521161120

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a)(3) · Plan of correction due date: Feb 21, 2023

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 ... This requirement was not met when resident sustained unstageable pressure injuries while in care which posed an immediate health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Feb 21, 2023

Plan of correction: An immediate civil penalty of $500 is being assessed for today’s visit. A Non-Compliance Conference (NCC) will be scheduled.

Allegation investigated: Neglect/ Lack of supervision resulting in resident sustaining multiple falls resulting in fracture Facility failed to follow residents care plan Resident is being financially abused Staff mishandled a resident's medications while in care

On 01/27/2023 starting at 10:45 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to deliver findings for the complaint investigation for the above allegations. LPA met with Caroline Koorn, and explained the purpose of the visit. 1. Neglect/ Lack of supervision resulting in resident sustaining multiple falls resulting in fracture On 06/03/2021, Licensing Program Analyst (LPA) Allison O’Hollaren initiated 10-day investigation and obtained records. Oakland Regional Office made a referral to Investigations Branch (IB) and was accepted as full investigation on 06/03/2021. On 08/01/2022, complaint was reassigned to L. Fontanilla who conducted pre investigation with Reporting Party (RP) on 08/04/2022. During the course of investigation, the Department obtained records including but not limited to Resident 1 (R1) medical records, death certificate and incident reports and conducted interviews. Continued on 9099C... Substantiated Continued from 9099... On 05/02/2021, R1 was seen at the John Muir Concord Medical Center for chief complaint of "back pain." R1 was diagnosed with a closed non displaced fracture of the greater trochanter of right femur. Thickening of the right gluteus maximus was noted, which suggested infiltrative hematoma. John Muir Concord Doctor believes the hip fracture and hematoma on the buttock are likely a result of a fall or similar type of trauma to the posterior. On 05/27/2021, R1 was sent to John Muir Concord Medical Center after an unwitnessed fall in the bedroom. Staff 1 (S1) reported that after R1 was tucked into bed, S1 went to assist another resident. S1 heard a sound in R1’s room. S1 immediately responded and witnessed R1 was slouching on the floor and bleeding from the head. R1 was immediately sent to the hospital. R1 had a head scan which showed acute left subdural hematoma with a 4mm left to right midline shift. On 05/28/2021, R1 was transferred to John Muir Walnut Creek Medical Center and was admitted to the Intensive Care Unit for a neurosurgery evaluation. Another head scan was conducted, and the subdural hematoma increased to 1.3 cm. File review documents and staff interviews conclude that R1 was a fall risk resident. R1 was unsteady while ambulating and sitting down. Fall mats and bed alarms were briefly used but were not successful and as such discontinued. Another fall prevention strategy was reminding R1 to use walker and reminding R1 to sit down. Staff stated that R1 required constant monitoring and supervision. R1 did not have one to one care. Some of the staff reported that R1 would have benefited from one to one care. S2 stated that R1 was beyond a level of care that the facility could provide based on R1’s need for constant supervision. R1 passed away prior to being interviewed. Death certificate lists his date of death as 06/05/2021 at 2210 hours. Immediate cause of death is listed as Traumatic Subdural Hematoma. Condition leading to the cause of death/underlying cause is Ground Level Fall. Continued from 9099C... Based on interviews and record review, the above allegation is substantiated. A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending. A Non-Compliance Conference (NCC) will be scheduled. 2. Staff mishandled a resident's medications while in care During the course of investigation, LPA L. Fontanilla reviewed facility medication list, nursing report and RCEB QA Review. On 3/29/2021, a medication error was recorded by Nursing Manager Ashton Paul when R1’s PRN suppository was not given as prescribed. A review of R1’s Medication Administration Record (MAR) from March 2021 to May 2021 show that R1’s PRN medicine Bacitracin ointment was not administered throughout the months of March and April 2021. Instructions indicate “apply as needed to open wounds or skin tears until healed.” Bacitracin was administered on May 1, 8, 21 and 26, 2021. A review of RCEB Home Annual Review indicate there were three (3) medication errors reported for 2020-2021. Based on record review, the above allegation is substantiated. 3. Resident is being financially abused On 8/12/2022, LPA L. Fontanilla reviewed an incident report dated 02/16/2021. The report indicates that R1 is missing $100 from P&I money. When staff counted the amount of cash in R1 and other clients’ binder, a significant amount of money was missing from R1’s and all the other clients’ P & I money. The above allegation is substantiated. Continued on 9099C... Continued from 9099C... 4. Facility failed to follow residents care plan Based on interview conducted with Reporting Party (RP), after R1 was diagnosed with a hip fracture, facility staff and Regional Center of the East Bay (RCEB) staff created a plan that bed alarms would be useful for R1. Facility staff reported that bed alarms and floor mats were implemented for R1’s safety but were unsuccessful and discontinued. Facility staff reported that R1 repeatedly unplugged the bed alarms. Based on interviews conducted, the above allegation is substantiated. Exit interview conducted a copy of this report and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Jan 27, 2023 · control 15-AS-20210602110415

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87468.1(a)(2) · Plan of correction due date: Jan 28, 2023

To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Based on investigation conducted by the Department, Licensee did not comply with the above section... ...R1 was a fall risk and required constant supervision. Facility discontinued using the fall mats and bed alarm. R1 had an unwitnessed fall on 05/27/2021 and died on 06/05/2021. Immediate cause of death is Traumatic Subdural Hematoma and condition leading to the cause of death/underlying cause is Ground Level Fall.the state’s words, verbatim · CDSS document, Jan 27, 2023

Plan of correction: A Non-Compliance Conference (NCC) will be scheduled. An immediate civil penalty of $500 is being assessed for today’s visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jan 31, 2023

Once ordered by the physician the medication is given according to the physician's directions. Based on record review, Licensee did not comply with section above. There were (3) documented medication errors observed in RCEB Home Annual Review for 2020-2021 which poses an immediate threat to health and safety of clients under carethe state’s words, verbatim · CDSS document, Jan 27, 2023

Plan of correction: Administrator will conduct medication training with staff and submit proof of training to CCL by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jan 28, 2023

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. Based on interviews conducted, Licensee failed to comply with section above. Facility staff interviewed state they discontinued the use of alarms and mats due to safety reasons. The plan on use of mats and alarms was created by RCEB and facility staff when R1 was diagnosed with a hip fracture.the state’s words, verbatim · CDSS document, Jan 27, 2023

Plan of correction: By POC date, Administrator will review and update the facility’s fall prevention plans for each client and submit a copy to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80026(e) · Plan of correction due date: Feb 3, 2023

Cash resources, personal property, and valuables of clients shall be separate and intact, and shall not be commingled with facility funds or petty cash Based on record review, Licensee did not comply with section above. On 2/16/2021, a large amount of money was missing from R1’s and other clients’ P&I money.the state’s words, verbatim · CDSS document, Jan 27, 2023

Plan of correction: By POC date, Licensee will submit to CCL plans on how to ensure clients’ P&I money are intact.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) J. Clancy-Czuleger conducted case management and met with Caroline Koorn. During the course of investigation, the Department observed: 1. Staff 1 (S1) was not located in LIS – 87411(g) 2. Facility staff failed to provide adequate care to R1 resulting in R1 sustaining pressure injuries - 87468.2 On May 28, 2021, R1 was seen at John Muir Walnut Creek after sustaining a fall resulting in a head injury. Medical records document R1 has a Stage 3 pressure injury on the left buttock and unstageable pressure injury on the mid-spine. Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct these deficiencies and/or repeat deficiencies within a 12- month period may result in civil penalties. Exit interview was conducted with Caroline Koorn and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Jan 27, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(g)(1) · Plan of correction due date: Jan 28, 2023

(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or Based on record review, the licensee did not comply with the section cited above. The Department observed S1 did not have fingerprint clearance while working at the facility which poses an immediate health and safety risk to the clients under care.the state’s words, verbatim · CDSS document, Jan 27, 2023

Plan of correction: Administrator will review Sec 87411 and submit statement of understanding to CCL by POC date. An immediate civil penalty of $500 is being assessed for today’s visit.

From the deficiency page — Deficiency type: Type A · Section cited: HSC87468.2 · Plan of correction due date: Jan 28, 2023

To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse Based on R1’s medical records, Licensee did not comply with section cited above. R1 sustained a Stage 3 pressure injury on the left buttock and unstageable pressure injury on the mid-spine.the state’s words, verbatim · CDSS document, Jan 27, 2023

Plan of correction: A Non-Compliance Conference (NCC) will be scheduled.

Type of visit: Required - 1 Year

On 11/28/2022 at 9:35 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct an annual Infection Control Inspection. LPA met with Lead Staff, Alexandria Jackson and explained the purpose of the visit. LPA spoke with Administrator, Caroline Koorn, on the phone. Administrator allowed Alexandria to sign this document. During the Infection Control Inspection, LPA toured facility with Alexandria including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient two day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. A sign-in policy, Covid questionnaires, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bins with touchless lids. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. Smoke and carbon monoxide detectors were observed. First Aid kit was complete. Fire extinguishers was observed serviced. LPA observed facility passages inside and out free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 28, 2022

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.