Brookdale Auburn

Allegation investigated: Staff allow the residents to be soiled for an extended periods of time Insufficient staffing to provide adequate care and supervision Staff do not practice safe food handling techniques Staff do not properly maintain the facility grounds Staff do not provide hygiene products Staff are chemically restraining the residents while in care Staff are mishandling the residents medications Staff are yelling at the residents while in care

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with Administrator Malissa Acuna during today’s inspection. LPA investigation allegation, “Insufficient staffing to provide adequate care and supervision”. LPA interviewed 5 residents that required care and supervision. 5 of 5 residents stated there are sufficient staff to meet their needs. 2 of 5 residents stated they have had to wait over 30 minutes for care at times. LPA interviewed 4 care staff at the facility, of which all stated there is sufficient staffing unless they have call offs. Care staff stated they are able to meet the residents’ care needs. Due to the information gathered LPA finds the allegation to be UNFOUNDED. Continuation on 9099-C. Unfounded LPA investigated allegation, “Staff allow the residents to be soiled for an extended periods of time”. LPA interviewed 5 residents in care in which they stated their care needs are being met. LPA interviewed 4 care staff in which they stated they have not observed residents soiled and left in an extended period of time. Care staff stated they have heard about times that has occurred, but they did not observe it. LPA interviewed administrator in which she stated she is not aware of residents being left soiled for an extended period of time. Due to the information gathered, LPA finds allegation to be UNFOUNDED. LPA investigated the allegation, “Staff do not practice safe food handling techniques”. LPA toured the facility kitchen, refrigerator, freezer, dry storage, and food preparation area. LPA observed 2-day perishable and 7-day nonperishable amount of food. LPA observed all food to be properly stored and all food appeared to be fresh and within the expiration date limits. Kitchen appeared to clean, sanitary, and free from smell. Due to the information gathered, LPA finds allegation to be UNFOUNDED. LPA investigated the allegation, “Staff do not properly maintain the facility grounds”. LPA interviewed 5 residents in which they stated the facility, and their room is kept clean at all times. 1 resident stated staff forget to empty their trash within their room on the weekends. LPA interviewed the administrator, in which she stated there is a housekeeper at the facility 7 days a week. Common spaces get cleaned daily, resident rooms get cleaned weekly, and sections of the facility get deep cleaned throughout the week. LPA interviewed 1 housekeeper in which she stated they clean the facility 7 days a week. LPA toured the facility and inspected common living spaces, resident rooms assisted living and memory care units, kitchen, and memory care unit. LPA observed the facility to be clean and sanitary with no smell present. Due to the information gathered, LPA finds the allegations to be UNFOUNDED. Continuation on 9099-C. LPA investigated allegation, “Staff do not provide hygiene products.” LPA interviewed 1 housekeeper in which they stated the facility provides the residents with basic hygiene items like toilet paper. LPA interviewed 5 resident in which they stated the facility provides them with basic hygiene products if needed. LPA interviewed administrator in which she stated there is a storage room full of basic hygiene items for residents if needed. LPA toured the storage room on the 2nd and 3rd floor which had toilet paper, soap, caregiver supplies, continence supplies, and other hygiene items. Due to the information gathered, LPA finds allegation to be UNFOUNDED. LPA investigated allegation, “Staff are chemically restraining the residents while in care.” LPA reviewed 4 resident medications, reviewing the present medications with resident MARS and physician orders. LPA interviewed 4 residents which required medication management from the facility staff. 4 of 4 residents stated they receive their medication daily and have had no problems with the medication management. LPA interviewed administrator in which she stated the medication technicians follow physician orders and give medications as prescribed. LPA interviewed 1 medication technician in which they stated if a hospice resident has a PRN medication order they call hospice before giving a PRN medication. Medication technician stated they follow medication orders which are on the resident MARS. Due to the information gathered LPA finds the allegation to be UNFOUNDED. LPA investigated, "Staff are mishandling the residents medications". LPA reviewed 4 resident medications, reviewing the present medications with resident MARS and physician orders. LPA interviewed 4 residents which required medication management from the facility staff. 4 of 4 residents stated they receive their medication daily and have had no problems with the medication management. LPA interviewed administrator in which she stated the medication technicians follow physician orders and give medications as prescribed. LPA interviewed 1 medication technician in which they stated they follow medication orders which are on the resident MARS. Due to the information gathered LPA finds the allegation to be UNFOUNDED. Continuation 9099-C. LPA investigated allegation, “Staff are yelling at the residents while in care.” LPA interviewed 5 residents in which they stated they have not been yelled at or observed any other resident being yelled at by facility staff. LPA interviewed 4 care staff in which they stated they have not observed any staff yelling at residents in care. LPA interviewed administrator in which she stated she has not observed any staff yelling at a resident in care. Due to the information gathered LPA finds allegation to be UNFOUNDED. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Oct 11, 2023 · control 59-AS-20230821112726

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to complete a case management visit. LPA met with Administrator Malissa Acuna during today’s inspection. During the complaint investigation, LPA discovered R1 was on hospice services. In September R1 went on a walk with activities with several other residents. During the walk R1 fell on the ground and was complaining of pain. Facility called hospice, and was told to wait for a hospice nurse to assess resident. R1 was helped up and moved back into the facility. Hospice arrived 2 to 3 hours later, and instructed staff to not send resident out for emergency services. The following day, resident was still in pain and facility sent resident out to the emergency department. R1 was diagnosed with a hip fracture and sent back to the facility on hospice services. Due to facility not calling emergency services upon R1’s injury which was not related to the expected course of the resident’s terminal illness, deficiencies are cited on 809-D. Exit interview conducted and copy of report provided. Appeal rights given.the state’s words, verbatim · CDSS document, Oct 11, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87469(c)(3) · Plan of correction due date: Oct 20, 2023

87469 Advanced Directives and Requests Regarding Resuscitative Measures (c) If a resident who has an advance directive and/or request regarding resuscitative measures form on file experiences a medical emergency, facility staff shall do one of the following: (3) Specifically for a terminally ill resident that is receiving hospice services and has completed an advance directive and/or request regarding resuscitative measures form pursuant to Health and Safety Code section 1569.73(c), and is experiencing a life-threatening emergency as displayed by symptoms of impending death that is directly related to the expected course of the resident’s terminal illness, the facility may immediately notify the resident’s hospice agency in lieu of calling emergency response (9-1-1). For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1). This requirement is not met as evidenced by: Based on interviews the licensee did not call emergency services for R1 upon fall at the facility which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 11, 2023

Plan of correction: Administrator agrees to conduct a training with all care staff regarding hospice residents and emergency services. Copy of training materials and staff sign in sheet to be sent into CCL by 10/20/23.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with Administrator Melissa Acuna during today's inspection. LPA ensured they applied hand sanitizer before entering the facility. LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 6 resident rooms, medication room, staff area, bathrooms, kitchen, common living spaces, outdoor spaces, activity areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the assisted living side of the facility and the memory care unit with a delayed egress. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete. LPA reviewed 7 resident files and 5 staff files. LPA reviewed medications of three residents comparing with Centrally Stored Medication Record and physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed. LPA observed a copy of current liability insurance. No deficiencies are being cited as a result of todays inspection. Exit interview conducted.the state’s words, verbatim · CDSS document, Jul 11, 2023

Allegation investigated: Failure to adhere to the admission agreement

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue investigation into allegations listed above. LPA met with Administrator Malissa Acuna during today's inspection. LPA investigated allegation, "Failure to adhere to the admission agreement". LPA interviewed relevant party in which they stated R1 and R2 are paying their rent on time every month, however since November 2022 residents continue to receive late payments. Facility has waived the late fees, however the mistake continues to occur. LPA reviewed R1 and R2's admission agreement in which it states, "We will charge a $250.00 late fee if we have not received all fees when due”. Continuation on 9099-C. Substantiated Facility continues to charge late payments to R1 and R2 which accorded to the admission agreement should only occur if all fees were not paid on time. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED. As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, May 17, 2023 · control 59-AS-20230510141127

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Jun 3, 2023

87507(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Based on record review, licensee did not comply with all applicable terms and conditions set forth in the admission agreement which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, May 17, 2023

Plan of correction: Administrator agrees to submit R1 and R2's billing statement for June which shows issue with billing has been corrected. POC due on 6/3/23.

Allegation investigated: Centrally stored medications are left unlocked Facility staff have not completed appropriate training's Facility is not kept clean Residents are not provided with proper food service Staff are smoking in the facility Staff left nicotine devices accessible to residents in care

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue investigation into allegations listed above. LPA met with Administrator Malissa Acuna during today's inspection. LPA investigated allegation "centrally stored medications are left unlocked". LPA conducted a facility tour which included 9 resident rooms, medication room, and common living spaces. LPA observed all medications are locked in the medication cart that is locked in the locked medication room. LPA did not observe unlocked medications in resident rooms or common areas. LPA interview facility staff and all staff state that medications are always locked in the medication cart and are not accessible to residents. LPA interview 3 residents in which they stated they have not observed medications unlocked. Continuation on 9099-C. Unfounded LPA observed on May 3rd through May 8th, medication was not provided to resident due to medication being out of stock at the facility. LPA observed R2 had an order for polyethylene glycol powder as a PRN medication, however medication was not available at the facility. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED. As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D. Exit interview conducted and appeal rights provided. Due to the information gathered, LPA finds allegation to be UNFOUNDED. LPA investigated allegation, "Facility staff have not completed appropriate training's", LPA reviewed facility staff training records, and observed staff have sufficient training to meet training requirements. LPA interviewed staff in which they stated they have online training and an all-staff training one time a month. Due to the information gathered, LPA finds allegation to be UNFOUNDED. LPA investigated allegation, "Facility is not kept clean". LPA conducted a facility tour which included 9 resident rooms, medication room, and common living spaces in the memory care unit and assisted living side of the facility. LPA observed that the facility was clean, safe and sanitary and odor free. LPA interviewed staff, and all staff stated the housekeepers keep the facility clean and are cleaning daily. LPA interviewed 3 residents in care in which they stated the facility is always clean. Due to the information gathered, LPA finds allegation to be UNFOUNDED. LPA investigated allegation, "Residents are not provided with proper food service". LPA inspected the kitchen and reviewed food menu. LPA observed fresh fruits, vegetables, and other food items. LPA interviewed 3 residents in care in which they stated food is served to them warm and they enjoy the food options. Food is brought into the memory care unit and placed into warming trays in order to keep the food warm. LPA interviewed memory care caregivers in which they stated food is served warm to the residents. Due to the information gathered, LPA finds allegation to be UNFOUNDED. Continuation on 9099-C. LPA investigated allegations, "Staff are smoking in the facility and staff left nicotine devices accessible to residents in care". LPA completed a facility tour in which LPA observed two smoking areas outside of the facility. LPA did not observed nicotine devices accessible to residents and LPA did not observe staff smoking in the facility. LPA interviewed staff in which they stated they have not observed staff smoking inside the facility and had not observed nicotine devices in the facility. LPA interviewed 3 residents in care, and all residents stated they have not observed staff smoking in the facility. Due to the information gathered, LPA finds allegation to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted.the state’s words, verbatim · CDSS document, May 17, 2023 · control 59-AS-20230303084533

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 18, 2023

87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by: Based on observation, licensee did not provide medications to residents as prescribed which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 17, 2023

Plan of correction: Administrator agrees to complete a training with all staff that dispense medications on proper communication and documentation. Date of training and subject matter to be sent into LPA by 5/18/23.

Allegation investigated: Facility staff are not giving new residents their medications for several days Facility staff are not following reporting requirements

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue investigation into allegations listed above. LPA met with Administrator Malissa Acuna during today's inspection. LPA investigated allegation, "Facility staff are not giving new residents their medications for several days and Facility staff are not following reporting requirements." LPA conducted interviews with staff and found that R1 moved into the facility on the evening of April 28th. Facility staff inputted medication orders in their system as self- administer and so MAR did not show resident required medication assistance. R1 did not receive medications as prescribed on April 29th through March 2nd. Continuation on 9099-C. Substantiated LPA investigated allegation, "Facility staff are not answering residents' call lights for assistance." LPA interviewed care staff in which they stated they respond as quickly as possible when a resident calls for assistance. LPA interviewed 3 residents in care in which they stated staff respond to their call light whenever they need care however at times it can take a long periods of time. Due to the information gathered, LPA finds allegation to be UNFOUNDED. Exit interview conducted. LPA found that the physician was notified on May 3rd however incident report was not sent into CCL. Due to the information gathered, LPA finds allegations to be SUBSTANTIATED. As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, May 17, 2023 · control 59-AS-20230505083122

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 18, 2023

87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by: Based on observation, licensee did not provide medications to residents as prescribed which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 17, 2023

Plan of correction: Administrator agrees to submit plan of how staff will manage new resident medications. Plan to be submitted into LPA by 5/18/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 31, 2023

87211 Reporting Requirements (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 is not met as evidenced by: Based on interviews and report review, licensee did not report incident into CCL which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, May 17, 2023

Plan of correction: Administrator agrees to review 87211 on reporting requirements, and write a statement of understanding of what needs to be reported to CCL. Statement to be sent into CCL by 5/31/23.

Allegation investigated: Staff are not following a licensed physician's orders Staff did not comply with an infection control practice Responsible party was not notified that resident was sick Staff refused to clean residents' room

Licensing Program Analyst (LPA) Bethany Mirlohi arrived to deliver complaint findings regarding the above allegations. LPA met with Administrator Malissa Acuna during today's inspect. LPA ensured she applied hand sanitizer before entering the facility. LPA investigated allegation, "Staff are not following a licensed physician's orders". During the investigation LPA reviewed documents, and conducted interviews with staff, residents, and relevant parties. R1 was taken to the emergency department and tested positive for covid on November 30, 2022. R1 returned home the same day and isolated in their room. LPA reviewed “After visit summary” documentation from the hospital in which it states to “follow these recommendations as told by your health care provider”. Continuation on 9099-C. Unsubstantiated Documentation then states the foods/drinks R1 should avoid and it states for R1 to eat bland, easy to digest foods like rice, bananas, applesauce, lean meats, toast and crackers. Relevant party indicates that the after visit summary was provided to the facility, however the bland foods were not provided to R1. Relevant party indicates that they had to follow up with facility for them to finally serve R1 bland foods like rice. LPA interviewed staff members in which they stated R1 refused a bland diet and so other foods were provided to R1. LPA reviewed facility documentation, in which they indicate on R1’s progress notes on 12/2/22 that R1 is requesting regular food to be brought to her because her health issues had resolved and R1 is feeling better. Due to the conflicting information LPA finds allegation to be UNSUBSTANTIATED. LPA investigated the allegation, "Staff did not comply with an infection control practice". LPA reviewed what facility reported to CCL in November 2022. Reports indicate facility had 3 covid positive clients between the time period of November 20th through November 30th 2022. 2 of 3 COVID positive clients were couple R1 and R2 who were sharing a room. All three clients were isolated in their rooms. LPA interviewed relevant party in which she stated R1 and R2 were never tested for COVID even though they were showing symptoms. Relevant party stated during the time period of R1 and R2 having symptoms and before they were tested, they were out in the facility around other residents. Facility had a different administrator during this incident time period and new administrator does not have documentation of communication with department of public health. Interviews with staff indicate that R1 and R2 were isolated upon testing positive for covid. LPA finds allegation to be UNSUBSTANTIATED. LPA investigated the allegation, "Responsible party was not notified that resident was sick."Relevant party informed LPA that facility failed to inform residents responsible party that residents (R1, R2) had a change of condition. Relevant party indicated that residents had covid like symptoms and facility staff never reported this to responsible party. Continuation on 9099-C. Relevant party indicated that responsible party found out from R1 about their covid like symptoms. Responsible party then took R1 to the emergency department and R1 tested positive for COVID. Relevant party indicated that R1 informed staff they were not feeling well and having symptoms however staff did not report this to responsible party. LPA interviewed R1 and they stated they could not remember who they reported covid symptoms too, and was unsure when they reported the covid symptoms to staff. LPA interviewed facility, in which they stated R1 and R2 are not on any care services and do not require help from staff. Staff indicated that R1 usually reports all changes of condition or any pertinent information to their responsible party and then the responsible party reports the issue with the facility. Staff are not aware of a time that they did not report changes with responsible party. Due to the conflicting information, LPA finds allegation to be unsubstantiated. LPA investigated allegation, "Staff refused to clean residents' room". During the investigation LPA interviewed staff, residents, and relevant party. Relevant party reported to LPA that facility refused to clean R1 and R2’s room when residents had tested positive for COVID and prior when they had symptoms. Relevant party stated that R1 had required extra cleaning due to an accident that occurred, and staff refused to help R1 clean. In addition, when R1 and R2 had confirmed covid cases housekeeping did not clean R1 and R2’s room. LPA interviewed maintenance Director assistant (MDA) which helps oversee housekeeping. MDA stated they do not remember that incident specifically however housekeeping cleans residents’ room even when residents are isolating due to COVID-19. MDA stated the housekeeping wear more PPE when entering a positive covid case room, and they continue to complete their weekly housekeeping duties. MDA stated that someone from housekeeping is at the facility from 8-5 and if a resident needs more cleaning due to an accident, housekeeping will help clean up. MDA stated he is unaware of a time housekeeping refused to help R1 and R2. LPA interviewed care staff in which they stated they do not recall a time that they refused to help R1 or R2 with cleaning up. Due to conflicting information LPA finds allegation to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. An exit interview was conducted. A copy of the report was provided to facility administrator.the state’s words, verbatim · CDSS document, Apr 6, 2023 · control 25-AS-20221201161953

Allegation investigated: Facility is not stopping the spread of COVID-19 Staff did not routinely change resident's clothes

On 3/1/2023 LPA Tryon visited the faciity to continue to work on the complaint. LPA self-screened for COVID symptoms prior to the visit. LPA met with Malissa Acuna, Executive Director. LPA has spoken with staff and witnesses, toured the facility and reviewed documentation. Regarding the allegation that the facility is not stopping the spread of COVID-19, LPA has spoken with staff and reviewed documentation. LPA learned that at the time of the allegation, the facility was routinely screening all visitors, staff and residents entering the facility. Temperatures were taken at the front door and visitors were screened.with questions regarding COVID symptoms. Staff and visitors were routinely wearing masks in the building. When there was a suspicion of a possible infection, isolation protocol was intiated, staff and residents were given tests thoughout the episode until clear. LPA also learned that resident R1 had moved into the facility from a hospital. R1 had only moved into the facility from the hospital when coming down with COVID. Because of this, it is not possible to say whether COVID may have been contracted in the facility, in the hospital, or somewhere else; or how it was spread. Therefore, LPA cannot say whether COVID was actually contracted at the facility; or that any action of the staff did or did not contribute to R1 becoming positive. Therefore, the allegation is Unsubstantiated. Unsubstantiated Regarding the allegation that Staff did not change resident's clothes, LPA spoke with staff, witnesses and reviewed documentation. LPA learned that resident R1 did apparently wear the same clothes for several days in a row at the facility. Staff said that they would offer R1 assistance to dress, and she would refuse or go back to the dirty laundry in the resident's room and switch clothes, putting on outfits previously warn. It appears that after a few days staff became aware that this was happening, and came up with a plan to remove the dirty clothes from the room, thus removing the possibility to change back to dirty clothes. R1 was new to the facility, and staff were not fully aware of her habits/behaviors at first. So, even though it does appear that R1 wore the same clothes for multiple days in a row, when staff became aware of the issue, it was dealt with appropriately. It does appear that assistance with dressing was included in the care plan, but LPA cannot say how much staff was aware of what assistance was really necessary for the first few days until they came to know R1. Allegation is unsubstantiated. required information. The facility attempted to bring this issue to the attention of the doctor's office, but the doctor was not available, and it took several days for the prescription to be written properly. It appears that the facility did make attempts to correct the situation and obtain the medications for R1, but was not able to get the mistake corrected immediately. This appear to have been an issue between the doctor's office and pharmacy that the facility did not have control over. It appears that facility staff did attempt to make R1's responsible party aware of the situation. So although it is true that the medication did not get filled as needed, the facility DID attempt to have it filled. Therefore, the allegation is unfounded. Regarding the allegation that Staff did not dispense prescribed medication to resident, as noted above, the facility attempted to have the medication filled, but due to an issue between the doctor's office and the pharmacy, it took a few days to obtain the medication. As noted above the facility staff made attempts to correct the issue, but it took some time, leaving resident without medication. This does not appear to have been caused by a mistake or omission of the facility, therefore, the allegation is unfounded.the state’s words, verbatim · CDSS document, Mar 1, 2023 · control 25-AS-20220815124721

Allegation investigated: Facility staff are not releasing past resident's records.

On 12/7/2022 LPA Tryon visited the facility to finish this complaint. LPA was screened at the door for COVID symptoms. LPA met with Ronica Rao, Business Office Coordinator. LPA has communicated with complainant and reviewed documentation. At this time, it appears that the facility has provided some documentation as per the request of the POA and representative of resident R1, but has not furnished several documents as spelled out on the request from POA and Representative. Documents that were requested but not provided were: LIC 602A Resident Appraisal; LIC 613C Personal Rights; LIC 621 Personal Property and Valuables; LIC 624 Unusual Incident Reports; LIC 622 Centrally Stored Medication Logs. Since these documents have still not been provided to POA/Representative as of this date, the allegation is SUBSTANTIATED. A finding of submstantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is cited as per Title 22, Section 87648.2 (a)(19). Appeal Rights provided, exit interview conducted.. Substantiatedthe state’s words, verbatim · CDSS document, Dec 7, 2022 · control 25-AS-20221109144603

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Dec 14, 2022

In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. This is not met as evidenced by: Facility failed to provide requested records to POA/Representative. This causes a potential violation of resident rights.the state’s words, verbatim · CDSS document, Dec 7, 2022

Plan of correction: The facility will furnish resident records to POA/their representative as per rerquest. Records to be furnished, and proof of delivery forwarded to CCL by 12/14/2022..

Allegation investigated: Staff forced resident to take medication that was not hers

On 11/9-2022 LPA Tryon visited the facility to open the complaint. LPA met with ED Morgan Whinery. LPA was screened at the door for COVID symptoms. LPA inteviewed Mrs. Whinery regarding the allegations. Regarding staff "forcing" resident to take medications that we not hers, LPA learned that recently a box of medication was dropped off with a Med Tech at the facility by a family member. A room number of the resident was written on the box. The box was in the med room for several days, then the facility contacted the doctor for the resident in the room written on the box and said a prescription was needed. The doctor agreed and wrote a new prescription for the resident IN THE ROOM listed. The medication was taken by a med tech to that resident, med tech showed the prescription to the resident, and resident took the medication. Resident later contacted family, who contacted the facility. In investigating the situation, the facility found out that the medication was actually brought by a family member of a resident with a similar room number for THAT resident. Therefore, even though the doctor did write up a prescription for the person who is the subject of this allegation, it was not truly meant for that person, but another. Therefore, the Substantiated facility did give it to the wrong person. Allegation is SUBSTANTIATED. A finding that an allegation is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is being issued as per Title 22 Regulations. Appeal rights provided, exit interview conducted.the state’s words, verbatim · CDSS document, Nov 9, 2022 · control 25-AS-20221103141901

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Nov 10, 2022

The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Through interivew of ED, LPA learned that the facility did in fact erroniously give resident R1 a medication intended for another residentthe state’s words, verbatim · CDSS document, Nov 9, 2022

Plan of correction: The facility will ensure that residents only receive medications intended for that resident. The Administrator will come up with a plan to safely check in medications brought to the facility by responsible parties, etc. to ensure accuracy of information. Plan due to CCL by 11/10/2022.

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

On this date, LPA Tryon and LPA Muscan visited the facility unannounced to deliver an immediate exclusion for staff S1. The document states that S1 cannot be present in or work with any residents of a facility licensed by the Department of Social Services. The Exclusion was delivered to facility Executive Director Morgan Whinery. While LPAs were at the facility staff S1 came in to work the daily shift. The staff was brought into the Executive Director's office and the Exclusion was delivered and read to S1. S1 was informed S! can no longer be present in or work with residents of a facility licensed by the Department. LPA asked S1 if there were any questions. LPAs then witnessed that S1 then left the facility. Exit interview conducted.the state’s words, verbatim · CDSS document, Aug 18, 2022

Allegation investigated: Staff member inappropriately touches female residents in care.

On 8/15/2022 LPA Tryon arrived at the facility to deliver complaint findings. LPA met with Executive Director Morgan Whinery. The Department has interviewed witnesses, residents, staff, Executive Director; obtained and reviewed documentation including incident reports, medical assessments, care plans, daily notes, staff schedules. Through interview of multiple witnesses and the accused staff, the Department has found that male staff S1 did on several occasions reach his hand down into female residents undergarments with his hand to check to see if the resident was wet and/or needed changing, as well as putting his face close to the crotch area of residents’ pants to smell if they were wet. Therefore, the allegation that staff member inappropriately touches female residents in care is SUBSTANTIATED. A finding that an allegation is Substantiated means that the preponderance of evidence standard has been met. The following deficiency is cited as per Title 22 Regulations and the Health and Safety Code. Exit interview conducted, appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 15, 2022 · control 25-AS-20220505090142

From the deficiency page — Deficiency type: Type A · Section cited: CCR 874681(a)(3) · Plan of correction due date: Aug 16, 2022

.Residents in all residential care facilities for the elderly shall have all of the following personal rights: 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 witnesses, residents and staff, the Department learned that staff S1 on at least one occasion did put his hand into the back of the pants of a female resident to check to see if she was dry or wet.the state’s words, verbatim · CDSS document, Aug 15, 2022

Plan of correction: .The facility will ensure that the safety, privacy and dignity of all residents is preserved at all times. The facility will ensure that staff undergo training regarding appropriate care and supervision of residents to ensure safety, privacy and dignity. The facility will submit a plan of training to CCL by 8/16/2022.

Type of visit: Case Management - Deficiencies

On 8/15/2022 LPA Tryon visited the facility to complete a complaint investigation. During the course of the investigation, Department of Social Services staff also found several other deficiencies related to the complaint that were not stated as allegations. During investigation, DSS staff learned that several staff had reported to investigators that staff S1 had acted in an inappropriate manner while working with facility residents in that he was witnessed sniffing the crotch of resident's undergarments to determine if the resident needed to be changed, did not wear gloves while providing incontinence care, and was seen sitting or kneeling on the floor close in front of a resident on the toilet while resident was using the toilet. DSS staff found there was no evidence that these incidents were ever reported to appropriate agencies by staff. Therefore, the facility is being issued a deficiency for failure to report.the state’s words, verbatim · CDSS document, Aug 15, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Sep 15, 2022

Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurence 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: 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. The facility failed to meet this requirement as evidence by: through staff interview, CCL staff learned that the staff reported that they witnessed another staff caring for a resident in an inapropriate way, and a report was not sent to DSS or other appropriate agencies.the state’s words, verbatim · CDSS document, Aug 15, 2022

Plan of correction: .The facility will ensure that all incidents or suspected incidents that may have the potential of causing harm to residents will be reported as per regulations. The facility will submit a plan to CCL detailing how this requirement will be met. Plan to be submitted by 9/15/2022.

Type of visit: Required - 1 Year

On 7/20/22 LPA Tryon arrived at the facility unannounced to conduct an annual visit using the Infection Control Domain of the CARES Tool. LPA had pre-screened for COVID symptoms prior to the visit. LPA met with Executive Director Morgan Whinery and Health and Wellness Director Yuriy Kutsenko. LPA reviewed the Infection Control Domain of the CARES Tool with staff. LPA toured the facility including common areas, dining room, kitchen, hallways, resident rooms, bathrooms, break room, storage, etc. The facility has a good supply of food of various types and good quality. There are plenty of PPE supplies on the premises, COVID tests, etc. The facility appears to be clean, well-furnished and in good condition. Residents participate in various activities and outings. At this time, the facility appears to be in overall compliance. No deficiencies were cited at this visit. Exit interview conducted.the state’s words, verbatim · CDSS document, Jul 20, 2022

Allegation investigated: Facility has not issue a refund.

LPA Tryon arrived at the facility unannounced on 7/11/2022 to open the complaint. Prior to the visit LPA had self-Screened for COVID symptoms, took my temperature, etc. LPA screened again at the entrance to the facility, used hand sanitizer, wore a mask. LPA met with ED Morgan Whinery. LPA informed her of the complaint and allegations. Ms. Whinery assured LPA that the facility IS working on giving the resident involved a FULL REFUND plus moving expenses; the company is in the process of gathering information to process the refund. The resident was only moved out a week ago and there has not been adequate time for the refund to be fully processed,. Although it is true that the refund has not been issued yet, it is in the process. Since the facility is already in the process of refunding all the resident's payments PLUS moving expenses, the allegation that the facility has not issued a refund is UNFOUNDED. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Unfoundedthe state’s words, verbatim · CDSS document, Jul 11, 2022 · control 25-AS-20220707131906

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87456(a)(2) · Plan of correction due date: Aug 11, 2022

87456 (a)Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement was not met as evidenced by: Initial assessment did not note prohibited health condition and 2 restricted health conditions that required extra care that the resident could not perform for self.the state’s words, verbatim · CDSS document, Jul 11, 2022

Plan of correction: The facility will ensure that each resident is given a complete and thorough assessment to learn and address all resident needs and conditions; and that the facility will be able to assist the resident if accepted. The facility will devise a plan for how ongoing assessments will be performed in the future. Plan to be submitted to CCL by 8/11/2022.

Type of visit: Case Management - Incident

On 6/20/2022 LPA Tryon visited the facility to follow up on an incident report sent in on 6/14/2022. Prior to the visit LPA had followed self-screening protocol for COVID as per policy, wore a surgical mask, used hand sanitizer, etc. Facility staff then screened LPA at the door, took my temperature, etc. The Incident Report in question stated that on 6/13/2022 a resident (R1) alleged a staff member had grabbed resident's arm in a rough way, and left bruising. LPA spoke with Executive Director Morgan Whinery. LPA learned that the facility has already thoroughly investigated the incident. The staff in question (S1) admitted to other staff that he did in fact grab resident's arm, when R1 got upset at him, although he said he did not realize he had grabbed it that hard. He also admitted this to his supervisor at the temporary staffing agency. The staffing agency then terminated the employment of S1 with that agency, and he will not be back to work at Brookdale. Brookdale ED had also filed the incident report with CCL, filed a SOC 341 Report of Suspected Abuse with the Ombudsman, filed a report with Placer County Sheriff, and notified resident's POA. LPA reviewed and obtained copies of documentation related to the incident and investigation. At this time, it appears that the staff and facility reacted to the report immediately and appropriately and dealt with the situation, reported appropriately, and the staff involved will no longer work at the facility. No deficiencies were cited at this visit. Exit interview conducted.the state’s words, verbatim · CDSS document, Jun 20, 2022

Allegation investigated: Untrained individuals are administering medications to residents.

LPA Tryon arrived at the facility unannounced on 4/15/2022 at 11:00 a.m. to continue to work on the complaint. LPA was screened at the door for COVID symptoms, temperature taken. LPA used hand sanitizer and wore a surgical mask. LPA has spoken with both current and former Executive Directors, interviewed staff, interviewed 5 residents, reviewed documentation. Regarding the allegation taht untrained individuals are administering medications to residents, CCL staff has interviewed former ED and staff. LPAs learned that the facility was using temporary staff from agencies quite a bit over the past couple of years. LPA learned that on several occassions the temporary agency staff was asked to pass medications to residents. The former ED stated to CCL staff that she did not verify that the agency staff had done medication training, as the agency does their own training. So, although the agency staff may or may not have had medication training, there is no written documentation to prove it. Therefore, since it cannot be proven, the allegation is SUBSTANTIATED. A finding that the allegation is substantiated means that the preponderance of the evidence standard has been met. The following deficiency is issued as per Title 22 Regulations. Appeal rights provided, exit interview conducted. Substantiatedthe state’s words, verbatim · CDSS document, Apr 15, 2022 · control 25-AS-20211018133106

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(4) · Plan of correction due date: Apr 18, 2022

All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: Knowledge required to safely assist with prescribed medications which are self-administered. This requirement is not met as evidenced by: The facility asked Agency staff to assist with medications without documentation that the staff had received appropriate training, posing a potential immediate danger.the state’s words, verbatim · CDSS document, Apr 15, 2022

Plan of correction: The facility will ensure that all staff responsible for assisting with medications have received appropriate training in safely assisting with self-administered medications. The Administrator will submit a plan describing how the faciltiy will ensure proper training and documentation in the future.

Allegation investigated: Facility over charged resident.

LPA Tryon arrived at the facility unannounced on 4/15/2022 at 11:00 a.m. to continue to work on the complaint. LPA was screened at the door for COVID symptoms, temperature taken. LPA used hand sanitizer and wore a surgical mask. LPA has spoken with witness, spoken with Executive Director, reviewed payment records. At this time, it appears that the facility has repaid the responsible party appropriately as per admission agreement/contract. Therefore, the allegation that the facility over charged resident is Unfounded. Exit interview conducted. Unfoundedthe state’s words, verbatim · CDSS document, Apr 15, 2022 · control 25-AS-20220119145025

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.

Allegation investigated: Staff speaks rudely to residents.

LPA Tryon arrived at the facility unannounced on 4/15/2022 at 11:00 a.m. to continue to work on the complaint. LPA was screened at the door for COVID symptoms, temperature taken. LPA used hand sanitizer and wore a surgical mask. LPA has interviewed witness, staff, Executive Director, and 5 residents. LPA learned that there was a staff person who did not always click with other staff members. It appears that the staff may have spoken gruffly with other staff, but in speaking with residents, ED and staff, LPA did not find evidence that staff S1 was ever rude to residents. It is possible that the staff could have been "rude", but it does appear that the staff met resident needs At this time, the staff in question is no longer employed at the facility. Since there is a lack of evidence to support that the allegation did or did not occur, Also, it is not clear that someone being "rude" as described in the complaint actually rises to the point of any kind of abuse. LPA finds the complaint to be Unsubstantiated. A finding that the allegation is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, appeal rights provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 15, 2022 · control 25-AS-20220316163222