complaint·June 6, 2024

Allegation: Staff do not maintain accurate records It has been reported that facility staff had no knowledge of a resident having dementia prior to 5/2024 as it was reported that a notice from UCLA was hand delivered in 2023 and was also emailed January 2024. Staff requested party to forward email of notice from UCLA that was allegedly sent to them 1/24, but notice was never received from the party and this party told Staff to check their emails for the notice. LPA observed an email dated 1/2/24 with attachments that did not contain any notice from UCLA Health. Notice for dementia was not received until 5/10/24. On 6/6/24 LPA observed an email dated 5/10/24 with attachments from UCLA Health re notification of dementia. It was also reported that facility staff did not have correct move out date for a resident. LPA observed a 30day notice dated 5/6/24, stating that resident will be out of the unit before 5/31/24. LPA observed an email dated 5/15/24 stating that the party will be changing moving date to next week, date TBD after meeting with attorney. On Friday 5/17/24, staff received email from the party stating that they have a crew coming next Sunday at 9am to remove resident’s items. The following Sunday’s date was 5/19/24, with no arrival of crew to collect resident’s belongings. Staff received another email from the party dated 5/20/24 stating that the MedCare transport will be coming Friday 5/24/24 at 10am. LPA interviewed staff S1-S6, LPA ask, does staff maintain accurate records. Of those interviewed, 5 out of 6 answered yes, and 1 staff that did not know. LPA interviewed residents R1 – R6, LPA ask, to your knowledge, does staff keep accurate records. Of those interviewed, 3 out of 6 answered yes and the other 3 did not know. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Con'd on 9099-C Allegation: Staff did not monitor a resident’s change in condition It is being reported that staff did not monitor residents change in condition, nor were family notified that resident had a change in condition. LPA learned that the resident was receiving home health through Remedy Home Health 11/2023. A new assessment was done and the resident went back on hospice services with Avila Hospice 1/4/24. Hospice staff never knew of family. Facility staff sent notice to CCLD regarding Hospice services 1/5/24. Staff notified, W1 about resident’s change in condition as W1 was the only contact person on record for emergencies. There was never any type of family contact with hospice services at all. The only family on record for emergency contact since admission was the resident’s son, who is now deceased. Facility staff could not update the party about residents medical condition as there was no POA on record nor a conservator. LPA interviewed staff S1-S6, LPA ask, does staff monitor residents for change in condition. Of those interviewed, 5 out of 6 answered yes, as 1 staff did not know. LPA interviewed residents R1 – R6, LPA ask, does staff monitor you for change of condition. Of those interviewed, 5 out of 6 answered yes, and 1 resident did not know. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Allegation: Resident left in soiled diapers for extended periods of time It was reported that a resident was left in soiled diapers for long periods of time and other residents providing this resident with incontinent supplies. During interviews, Con'd on 9099-C LPA Shirley learned that residents are monitored and staff do frequent checks for residents with incontinence issues. This resident was also on Home Health services and then Hospice services in which both provided incontinence products to residents that are receiving services. Per S6, resident was not receiving incontinence products from other residents. Borrowing from other residents is not allowed. LPA interviewed staff S1-S6, LPA ask, are residents left in soiled diapers for extended periods of time. Of those interviewed, 4 out of 6 answered no as 2 staff did not know. LPA interviewed residents R1 – R6, LPA ask, have you ever been left in your diaper for an extended amount of time. Of those interviewed, 5 out of 6 answered no and 1 resident said yes. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated Allegation: Staff are not allowing resident’s responsible party to remove resident from facility It is being reported that family found another facility for the resident as the resident does not have the resources to stay at this facility. LPA Shirley learned through interviews that this resident does not want to leave this facility and has been vocal about it. S1 stated that she will honor the request for this resident to be relocated if the resident chooses to leave this facility without any refusal or struggle. Upon LPAs return to Brookdale, LPA learned that the resident left with no problems or resistance. LPA interviewed staff S1-S6, LPA ask, does staff allow resident’s responsible party to remove residents from this facility. Con'd 9099-C Of those interviewed, 4 out of 6 answered yes and 2 staff did not know. LPA interviewed residents R1 – R6, LPA ask, is staff not allowing your responsible party to remove you from this facility. Of those interviewed, 3 out of 6 answered, yes and 3 did not know. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of the LIC 9099 was provided to Executive Director, Mia Nakamatzu.