Brookdale Chanate

Based on LPA's/ED observation, interview and record review, the licensee did not comply with the section cited above in two resident's toilets were observed dirty, one located in the assisted living and one located in the memory care unit. Based on records review, the facility housekeeping schedule revealed that the dirty toilet should have been cleaned today by 10am which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPAs observation and interview with administrator the facility failed to label and or cover two prepared left over fruit cups and tray containing at least 38 pieces of food were observed uncover and not labeled which poses a potential health and safety risk to residents in care.

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met by: Based on self-incident report the licensee did not comply with section above by not properly assisting R1 with their prescribed medication Namenta 5mg and 10mg resulting in overdosing resident in care, which poses an immediate health, safety or personal rights risk to persons in care.

87625 Managed Incontinence (b) In addition to Section 87611... the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met by licensee as evidenced by: Based on LPA interviews of facility's pendant call button system log, the licensee did not comply with the section cited above in that two [2] out of [2] residents that require staff assistance to manage and change their briefs waited long periods of time before staff arrived to change them, on least two occasions they waited over an hour, hich poses a potential health, safety or personal rights risk to persons in care.

§1569.269 Enumerated rights... a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by: Based on LPA record review of facility's pendant call button system log, the licensee did not comply with the section cited above in that between 2/9/25 and 2/13/25 residents pushed their pendant call button at least 192 times. Of those 192 times at least 42 never got a response, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that Automatic Sprinkler System failed inspection per vendor inspection report and the Emergency exit door at the end of the AL hallway (NW exit hall #2) was propped open with a brick, which poses an immediate health, safety or personal rights risk to persons in care. *amended to include deficient practice statement language and plan of correction language due to computer printing error.**

Based on LPAs observation, the licensee did not comply with the section cited above in that LPA observed notable urine smell coming from room next Sauna room in Memory Care, which poses a potential health, safety or personal rights risk to persons in care. **amended to include deficient practice statement language and plan of correction language due to computer printing error.**

Based on LPAs record review, the licensee did not comply with the section cited above in that Administrator's certificate was in renewal status but was subsequently removed from pending status due to not having enough training hours completed and required forms not submitted, which poses an immediate health, safety or personal rights risk to persons in care. **amended to include deficient practice statement language and plan of correction language due to computer printing error.**

Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S5, S6, S7, S8, S9, S10, and S11 did not have fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care. *amended to include deficient practice statement language and plan of correction language due to computer printing error.* ***civil penalties assessed***

Based on LPAs and Admin observation, the licensee did not comply with the section cited above in that LPAs observed trash, food scraps and pieces of discarded food items, cup with black substance and white substance, and used paper towels to be discarded and piled up underneath sink in Memory Care kitchen, which poses a potential health, safety or personal rights risk to persons in care.**amended to include deficient practice statement language and plan of correction language due to computer printing error.**

Based on LPAs and Admin observation and record review, the licensee did not comply with the section cited above in that S1, S2, S3, and S4 did not have the required number of training hours completed, which poses a potential health, safety or personal rights risk to persons in care. **amended to include deficient practice statement language and plan of correction language due to computer printing error.**

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports...: (1) A written report shall be submitted to the licensing agency...for the resident within seven days of the occurrence of any of the events...(D) Any incident which threatens the welfare, safety or health of any resident...This requirement was not met by licensee as evidenced by: CCL did not receive an Incident Report for R1's medication error, which poses a potential health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met by licensee in that another resident's medication was administered to R2, which poses an immediate health, safety or personal rights risk to persons in care.

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met by licensee as evidenced by: Facility did not provide resident's authorized representative with the correct refund and facility billed resident's authorized representative after resident's departure from facility for incontinence items, which poses a potential health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met by licensee as evidenced by: Based on LPA record review, R1 received the incorrect dosing of Sevelamer from 11/27/24 through 12/16/24, which poses an immediate health, safety or personal rights risk to persons in care.

Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted. Licensee did not meet this requirement as evidenced by; interim administrator does not have fingerprint clearance. This poses an immediate Health, safety or personal rights risk to residents*civil penalty assessed*

Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator. Licensee did not meet this requirement as evidenced by: interim Administrator does not have an actively current Administrator certificate. This poses an immediate Health, safety or personal rights risk to residents

87705 Care of Persons with Dementia(c)(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidenced by: incident of resident elopment, which poses a potential health, safety or personal rights risk to residents in care.

Based on record review and observations made, the Licensee did not comply with the section cited above. Licensee did not ensure that a resident routine medications were documented and centrally stored as required. This poses a potential health, safety or personal rights risk to residents in care.

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: based on record review, the Licensee did not comply with the section cited above. Multiple call records showed that residents waited for at least 30 minutes or longer to receive assistance from care staff or did not receive assistance at all. This poses an immediate health, safety or personal rights risk to residents in care.

87303 Maintenance&Operation (i) Facilities shall have signal systems...:(1)All facilities licensed for 16 or more...(A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce... signal...loud enough to summon staff. This requirement was not met as evidenced by: based record review and interviews conducted, Licensee did not comply with section cited above. Facility call cords need replacement and pagers don't always indicate resident calls. This poses an immediate health, safety or personal rights risk to residents in care.

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. Licensee did not meet this requirement based on document review confirming that the call bells for multiple residents was not responded to by staff. This is an immediate risk to the health and safety of residents in care.

87464 Basic Services A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement was not met as evidenced by interviews revelaing that there is not always incontinence supplies resulting in staff using supplies from other residents.

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. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports...This requirement was not been met as evidenced by interviews and record review showing that caregivers have worked by themselves despite residents requireing two-person assists. This is an immediate risk.

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. Plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with with self-administered medications as needed. This requirement was not met as evidenced by report review showing that two residents were not provided medications as prescribed. This is an immediate risk to health and safety of residents.

87211 Reporting Requirement (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following: (1) A written report shall be submitted to the licensing agency & to person responsible for the resident within 7 days of the occurrence of any of the events specified in (A) through (D) below...(A) Death of any resident from any cause regardless of where the death occurred... Licensee didn't meet requirement as evidenced by: Based on interviews & document review death report was not provided to responsible person.

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. Licensee did not meet this requirement based on interviews that confirm not all resident's needs were met timely due to the signal system being down and staff not being able to supervise per stated protocol. This is an immediate risk to the health and safety of residents in care.

87303 Maintenance&Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit. Requirement not met based on interviews indicating signal system was inoperable for multiple weeks.

Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit Requirement has not been met based on review of review of call logs for resident over a f15 day period showing that out of 125 calls, 42 of them were responded to 15 minutes or later and 6 were not responded to. This is am immediate risk to health and safety.

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement has not been met based on interviews showing that S1 raised their voice at a resident. This is an immediate risk to personal rights.

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement has not been met as evidenced by interview and document review showing that resident eloped the facility despite not being able to be in the community by themselves. This is an immediate risk to the health and safety nof residents in care.

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional & social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains... are observed, the licensee shall ensure that such changes are documented & brought to the attention of the resident's physician & the resident's responsible person, if any. Requirement hasn't been met as evidenced by facility not notifying doctor of weight loss. This is an immediate risk to the health and safety nof residents in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a) 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: (1) To have a reasonable level of personal privacy in accommodations... This requirement has not been met as evidenced by interviews confirming that a resident in memory care goes into other resident's rooms and goes through their personal items. This is a potential risk to the personal rights of residents in care.

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement has not been met as evidenced by interview and observation showing that a resident was left in a soiled brief until after eating and resident's room smelled of urine. This is an immediate risk to the health and safety nof residents in care.