complaint·April 19, 2021

Regarding the allegation that staff mismanaging resident’s medication, LPA reviewed facility incident reports, staff statements and facility medication records. On 10/9/20, as reported on an LIC 624- Incident report form, R12 did not receive prescribed medication due to lack of refill request by facility staff. R12 was sent to emergency room for medication refill. In addition to this documented error, staff (S1, S2, S3 and S6) reported in interviews with LPA Mknelly that medication errors such as missed medications, delays in medication refills and delays in medication administration times are regularly occurring. The staff interviewed attributed the errors to under-staffing causing distractions to med techs and inexperienced med techs making errors. LPA was referred by staff to check the facilities medication records and care notes for recording of errors. LPA was also told by S2 and S3 that known errors were not recorded by staff due to lack of time to record and staff attempts to omit their mistake. One example that bore this out was in March 18, 2021, R6 was mistakenly given R7’s Lorazepam 1 mg tab when R6’s order was for a .5 mg tab. During LPA’s investigation, Lori Fries RN, District Director of Clinical Services, initially stated that there was no known incident in March with these residents. Upon further investigation of facility records and interviewing staff, she found that the internal reporting system was not properly used by staff. 87465 (a)(5) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility…by compliance wi th the following: (5) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evident from records and statements that R12 was not provided medication. This poses an immediate risk to residents in care. This is a repeat violation in 12 months. Civil penalties to be issued. Regarding the allegation that resident’s hygienic care needs are not being met, LPA reviewed resident records, facility records and staff statements. At the initial investigation visit, on 9/29/20, facility there were 28 residents in care. On 10/19/21 LPA found in records and statements that on 10/17/20 and 10/18/20, only one med tech and one caregiver started each shift with 28 residents in care. On 10/19/20, after 1 overnight caregiver and the med tech left at 6 AM, S2 was the only staff as others did not show up. S2 made calls for assistance. Wellness Director, Sumit Benipal and an LVN from another Brookdale arrived to assist. Resident R21, who is on hospice and is a two person assist, was in heavily soiled depends with a stage three ulcer contaminated. Resident R2, who is a two person assist for behaviors, has been resistant to incontinence care and due to time limits of staff is refusing and not changed regularly. On 12/25/20, LPA called the facility for a Covid-19 follow-up call and was informed that there were 3 staff working with 21 residents. On 1/10/21, LPA called the facility for a Covid-19 follow-up call and was informed that there were 2 staff working with 21 residents. In a caregiver interview, LPA was informed that on 3/8/21 there were two staff caring for 21 residents on the morning shift. On 3/13/21, LPA conducted an in-person facility inspection and was informed that there 15 residents with incontinent, nine who require Ambulation assist or cuing for transfers or falls safety, 4 require Dinning Assist, five require two- person assist with transfers and activities of daily living and two are 1:1 for behaviors. On this day, there were two caregivers, a med tech and two additional agency staff for two one-to-one residents present, a house keeping staff, Activities Director and the LVN present at 10 AM in the morning. Care staff and management stated that this is the proper staffing for current residents and their care needs. 87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as neede d by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. Regarding the allegation that residents are not being provided activities, Interviews found that 87219 Planned Activities (e) In facilities licensed for sixteen (16) to forty-nine (49) persons, one staff member, designated by the administrator, who has the primary responsibility for the organization, c onduct and evaluation of planned activities was not present at the facility Sept 2020- March 2021. A new Activities Director has been hired approximated 3/13/21. Staff reported that they were directed to offer resident activities during the activities directors’ vacancy, yet they were often unable to due to the demands of residents’ care and supervision. Regarding the allegation that facility is not adequately staffed to meet residents’ needs, LPA reviewed facility schedules and timecards and staff statements. In September 2020, there were four resident-to-resident altercations between 9/22/20 and 9/30/20. All occurred in the facility’s common areas and staff were not present when the incident started. On 9/22/20 R10 pushed R1 resulting in R1’s compression fracture. On 9/24/20, R10 pinched R9 resulting in bruising to R9. On 9/27/20, R2 grabbed and would not release R11. Agency staff were present but ineffective. On 9/30/20 R15 and R16 were yelling at each other, throwing food, and grabbing each other. R15 sustained a skin tear. In January and February 2021, there were another 8 such incidents. Wellness Director, Sumit Benipal reported these incidents to LPA Mknelly on 3/13/21 stating they had not been trained to report these incidents to Community Care Licensing (CCL). R1, on 9/22/20, had a fall with compression. Staff interviewed (S2, S3 and S9) stated R1 was known to reach over others for food and R10 stated that they had pushed her away when she reached over him. Staff were not present in the area though both residents were known to have these behaviors. LPA had been told by Administrator Jennifer Scarberry, on 9/29/20, that agency staff are utilized primarily as “floater” support for staffing shortages due to the special needs of residents. However, staff reported that agency staff have been discontinued do to cost. LPA review of records found that many staff shortages were not filled by agency staff. LPA also conducted extensive Covid -19 outbreak contacts where staff shortages were explicitly inquired about and denied by the Administrator. 10/19/20 LPA found in records and statements that on 10/17/20 and 10/18/20, a med tech and a caregiver started each shift with 28 residents in care. On 10/19/20, after 1 overnight caregiver and the med tech left at 6 AM, S2 was the only staff as others did not show up. S2 made calls for assistance. Wellness Director, Sumit Benipal and an LVN from another Brookdale arrived to assist. Resident R21, who is on hospice and is a two person assist, was in heavily soiled depends with a stage three ulcer contaminated. Resident R2, who is a two person assist for behaviors, has been resistant to incontinence care and due to time limits of staff is refusing and not changed regularly. On 12/25/20, LPA called the facility for a Covid-19 follow-up call and was informed that there were 3 staff working with 21 residents. On 1/10/21, LPA called the facility for a Covid-19 follow-up call and was informed that there were 2 staff working with 21 residents. S1, S2, S3, S4, S5, S6 and S9 stated during interviews that during the period of Aug-Sept of 2020, and continuing up to 3/8/21, staffing was often not sufficient to meet the needs of the residents. Reported in interviews by staff, when there were days with one caregiver assigned to 10-13 residents with incontinence waited to be changed when soiled, residents with ambulation assistance needs would not always wait for assistance and falls had occurred as a result, residents who required assistance with eating would have their meals delayed, showers were often missed, medications at times were delayed and behavioral altercations took place in common areas when staff were attending to individual residents. On 3/13/21, LPA conducted an in-person facility inspection , there were 20 residents in care and LPA was informed by staff present that there five residents receiving Hospice, six residents with regular behavioral disturbance, 15 Incontinent, nine who require ambulation assist or cuing for transfers or falls safety, 4 require dining assist, five require two- person assist and two are 1:1 for behaviors. 10/19/20 LPA found in records and statements that on 10/17/20 and 10/18/20, a med tech and a caregiver started each shift with 28 residents in care. On 10/19/20, after 1 overnight caregiver and the med tech left at 6 AM, S2 was the only staff as others did not show up. S2 made calls for assistance. Wellness Director, Sumit Benipal and an LVN from another Brookdale arrived to assist. Resident R21, who is on hospice and is a two person assist, was in heavily soiled depends with a stage three ulcer contaminated. Resident R2, who is a two person assist for behaviors, has been resistant to incontinence care and due to time limits of staff is refusing and not changed regularly. On 12/25/20, LPA called the facility for a Covid-19 follow-up call and was informed that there were 3 staff working with 21 residents. On 1/10/21, LPA called the facility for a Covid-19 follow-up call and was informed that there were 2 staff working with 21 residents. S1, S2, S3, S4, S5, S6 and S9 stated during interviews that during the period of Aug-Sept of 2020, and continuing up to 3/8/21, staffing was often not sufficient to meet the needs of the residents. Reported in interviews by staff, when there were days with one caregiver assigned to 10-13 residents with incontinence waited to be changed when soiled, residents with ambulation assistance needs would not always wait for assistance and falls had occurred as a result, residents who required assistance with eating would have their meals delayed, showers were often missed, medications at times were delayed and behavioral altercations took place in common areas when staff were attending to individual residents. On 3/13/21, LPA conducted an in-person facility inspection , there were 20 residents in care and LPA was informed by staff present that there five residents receiving Hospice, six residents with regular behavioral disturbance, 15 Incontinent, nine who require ambulation assist or cuing for transfers or falls safety, 4 require dining assist, five require two- person assist and two are 1:1 for behaviors. During this inspection there were two caregivers, a med tech and two additional agency staff for two one-to-one residents present, a house keeping staff, Activities Director and the LVN present at 10 AM in the morning. Care staff and management interviewed stated that this is the proper staffing for current residents and their care needs. Facility staff reported to LPA that on the overnight shift of 3/26/21 -3/27/21, three staff were working- S12 med tech, S13 on call caregiver until 4 AM, and caregiver S14 who left unannounced "sick" at approximately 2:20 from Cottage (wing of the facility. S2 did not inform S12 or S13 of their departure. Cottage house has residents who need frequent care, hospice residents need checks, resident repositioning (R18), residents with falls or behaviors. There were only two staff 2:20-4 PM. S14 was not known to be gone until 3:50 AM. Med tech S12 was the only staff 4-5 AM. Housekeeping arrived at 5. AM staff arrived at 6 AM. 87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by records and statements that found insufficient staff to meet resident needs. This posed an immediate risk to residents. Resident’s records are incomplete – Sharon Porter LIC 602 dated 11/19/18 at the time of her 9/22/20 fall with compression fracture. A residents’ record review of LIC 602 Physician Reports, which are required annual and for significant change of condition for residents with dementia, were more than 12 months old for R1, R3, R5 and R19 at the time of recorded falls or behavioral incidents. 87705 Care of Persons with Dementia (e) (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by records review with found of five of eight records reviewed has expired annual medical assessments. This posed a potential risk to residents. As a result of this investigation, LPA finds allegation 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. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Unable to obtain signature. Signature present on hard copy in file. LPA sent a copy of report for Sharon Monck to sign. Administrator to send a signed copy back to CCL. Additionally, LPA sent a copy of the appeal rights.