Other·December 24, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during a Complaint investigation. Complaint No: CA00706557 Representing the Department of Public Health: Health Facilities Evaluator, Nurse: 42561, RN, HFEN The inspection was limited to the specific complaint investigation and does not represent the findings of a full inspection of the facility. There were two deficiencies issued for Complaint No: CA00706557.

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 12/03/2020 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BEWE11 Facility ID: CA940000069 If continuation sheet 1 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056014 (X3) DATE SURVEY COMPLETED 11/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKFIELD HEALTHCARE CENTER 9300 Telegraph Rd Downey, CA 90240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to treat two of 4 residents (1, 3), who spoke other languages other than English, with dignity by ensuring the staff understood the residents needs. The deficient practice had the potential to cause physical and psychosocial harm to Resident 1, 3, and other residents who did not speak the primary language of the facility and their needs were not being met due to the language barrier. Findings: On 10/08/2020 at 2:37 p.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BEWE11 Facility ID: CA940000069 If continuation sheet 2 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056014 (X3) DATE SURVEY COMPLETED 11/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKFIELD HEALTHCARE CENTER 9300 Telegraph Rd Downey, CA 90240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE interview with Certified Nursing Assistant (CNA 1) stated Resident 1 spoke English. On 10/08/2020 at 2:50 p.m., during an interview with Resident 1 stated he spoke Greek. A review of Resident 1's Facesheet (admission record) indicated the resident was admitted to the facility on 7/09/2018 with diagnoses including hypertension (high blood pressure), hemiplegia and hemiparesis (paralysis on one side of the body), and dementia (memory disorder). A review of Resident 1's Minimum Data Set (MDS) a standardized care screening tool dated 10/03/2020, indicated the resident had severe cognitive impairment for daily decision making. A review of Resident 1's care plan dated 8/28/2019 and revised 10/09/2020, indicated the resident was at risk for communication problems because of speaking Greek. The interventions included providing a translator as necessary to communicate with the resident. On 10/08/2020 at 2:52 p.m., during a concurrent observation and interview with Resident 2, who was the roommate of Resident 2 stated Resident 1 spoke Greek. However, Resident 2 stated staff spoke to Resident 1 in English. During interview Resident 2 stated the two weeks he was roommates with Resident 1, Resident 2 did not see or hear a translator being used when staff communicated with Resident 1. A review of Resident 2's Facesheet indicated the resident was admitted to the facility on 8/17/2020 with diagnoses including diabetes (abnormal blood sugar levels), hypertension, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BEWE11 Facility ID: CA940000069 If continuation sheet 3 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056014 (X3) DATE SURVEY COMPLETED 11/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKFIELD HEALTHCARE CENTER 9300 Telegraph Rd Downey, CA 90240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and gastritis (inflammation of the stomach lining). A review of Resident 2's MDS assessment dated 10/04/2020, indicated the resident was moderately cognitively impaired with daily decision making. On 10/08/2020 at 3:05 p.m., during an interview with CNA 2 stated Resident 1 spoke Greek but also some English. During interview CNA 2 stated he spoke to Resident 1 in English and had not used interpreter service to ease the communication between the resident and staff members. During interview CNA 2 stated the residents in the facility mainly spoke English or Spanish. The CNA 2 stated that was the main language of the facility, staff spoke the same language, and were able to translate when needed. On 10/08/2020 at 3:08 p.m., during a concurrent observation and interview with Resident 1 (using the facility's interpreter service) the resident was observed speaking Greek. During the interview Resident 1 alleged two nurses hit him in the groin area (observed Resident 1 point to his groin) one time each with his back scratcher. Resident 1 stated he informed CNA 1 of this incident but the facility did nothing. Resident 1 stated on a scale of one to 10 (zero being no pain and 10 being the most excruciating pain) the pain experienced was strong and painful, and rated the pain five out of 10 when he was hit. Resident 1 stated he felt bad at the time because he did not expect women to do "such an act." On 10/08/2020 at 3:38 p.m., during an interview with the Director of Nursing (DON) stated there was only one staff member with the same first name as CNA 1 who worked in the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BEWE11 Facility ID: CA940000069 If continuation sheet 4 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056014 (X3) DATE SURVEY COMPLETED 11/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKFIELD HEALTHCARE CENTER 9300 Telegraph Rd Downey, CA 90240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 10/14/2020 at 11:22 a.m., during a concurrent observation of Resident 3's room and interview with CNA 3 stated Resident 3 spoke Tagalog and small phrases of English. When asked about Resident 3's concerns CNA 3 stated he did not know because Resident 3 spoke Tagalog. During interview CNA 3 stated he relied on the body language to communicate with the resident. CNA 3 stated Resident 3 pulled on her incontinent briefs when it needs to be changed. CNA 3 stated he was not aware of any interpreter services offered at the facility and had not seen any postings that an interpreter services were available. CNA 3 stated the residents whose primary language was not English were provided with a communication board (a device that displays photos, symbols, or illustrations to help people with limited language skills express themselves where the user can gesture, point to, or blink at images to communicate with others) that are supposed to be kept close to the resident or on their wheelchairs. During observation conducted with CNA 3, there was no communication board in sight in Resident 3's room. During interview CNA 3 stated there was no communication board used to communicate with Resident 3. CNA 3 stated he was not aware if there were any communication boards available for staff to refer to, but stated was going to ask the charge nurse about it. During a review of Resident 3's Facesheet indicated the resident was admitted to the facility on 8/11/2014 with diagnoses including metabolic encephalopathy (disorder of the brain), insomnia (inability to sleep), and dementia. A review of Resident 3's MDS assessment dated 7/26/2020, did not have record of the resident's cognitive status was left blank. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BEWE11 Facility ID: CA940000069 If continuation sheet 5 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056014 (X3) DATE SURVEY COMPLETED 11/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKFIELD HEALTHCARE CENTER 9300 Telegraph Rd Downey, CA 90240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 3's care plan dated 11/24/2014 and revised 10/09/2020, indicated the resident was at risk for communication problems because of speaking Tagalog, which was the resident's primary language. The interventions included providing a translator as necessary to communicate with the resident. On 10/14/2020 at 11:36 a.m., during a concurrent observation of and interview with Resident 4 (with CNA 3 acting as an Spanish interpreter) observed a communication board on Resident 4's bedside table containing pictures that included English and Spanish words. During interview CNA 3 stated Resident 4 did not speak English but spoke Spanish. During interview Resident 4 stated nurses who do not speak Spanish bring "what they want to ask", such as an incontinent brief to be changed. During interview Resident 4 stated if he wanted to communicate something to a nurse that did not speak Spanish, nothing would happen. The resident stated stated nurses do not get a translator to communicate with him; Resident 4 confirmed translation services were are not provided to him to ensure the needs were met in a timely manner. During a review of Resident 4's Facesheet indicated the resident was admitted to the facility on 6/30/2018 with diagnoses including diabetes, hypertension, anemia (low level of red blood cells), and Alzheimer's disease (a type of dementia). During a review of Resident 4's MDS assessment dated 9/15/2020, indicated the resident had severe cognitive skills for daily decision making. On 10/14/2020 at 11:46 a.m., during an interview with Licensed Vocational Nurse (LVN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BEWE11 Facility ID: CA940000069 If continuation sheet 6 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056014 (X3) DATE SURVEY COMPLETED 11/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKFIELD HEALTHCARE CENTER 9300 Telegraph Rd Downey, CA 90240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1)stated communication boards and an interpreter service were available for staff to use when communicating with the residents who were not able to speak English. During interview LVN 1 stated communication boards were hung on the residents' bed rails or placed inside their nightstand. During observation LVN 1 showed a posting at the Station 2 nurses station titled 'Language Line/Interpreter Services,' and stated she used the interpreter service but had not used it a "quite a while" because most of the residents at the facility spoke English. LVN 1 stated she last had an inservice on how to use the interpreter service by the previous Director of Staff Development (DSD) about a month ago. On 10/14/2020 at 11:50 a.m., during a concurrent observation of Resident 2's room and interview with LVN 2 stated she communicated with Resident 2 using a communication board. LVN 2 attempted to search for Resident 2's communication board but was unable to locate it and stated it was supposed to be on or above the nightstand. LVN 2 stated Resident 2 spoke some English and was able to use Resident 2's family member to translate since she was a physical therapist working at the facility. LVN 2 stated staff could also use a phone number to translate if Resident 2's family member or communication board were not available. LVN 2 stated the current DSD provided an in-service on how to use the interpreter service last week. On 10/14/2020 at 11:57 a.m., during an observation of the Station 1 nurses station, observed a posting on the wall titled 'Language Line/Interpreter Services.' On 10/14/2020 at 11:58 a.m., during an interview with the DSD stated she provided an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BEWE11 Facility ID: CA940000069 If continuation sheet 7 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056014 (X3) DATE SURVEY COMPLETED 11/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKFIELD HEALTHCARE CENTER 9300 Telegraph Rd Downey, CA 90240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE in-service on how to use the interpreter service last week on 10/06/2020. The DSD stated she gave an in-service on abuse and language/communication concurrently because language could be used in an abusive way at any time, including verbal abuse. The DSD stated the facility's activities services provides communication board to the residents who needed them. On 10/14/2020 at 12:15 p.m., during an interview with the Activities Aid (AA) stated newly admitted residents were interviewed to identify their preferences and language spoken. The AA stated she had a supply of communication boards in many different languages available and made copies for the resident's primary language once it was identified. The AA stated there were many staff members who spoke Spanish and Tagalog but reminded the staff to also use the interpreter service. The AA stated there was one resident in the facility who spoke Greek. The AA stated Residents 1 and 2 both had communication boards, which should had been kept by their bedside. During observation with AA into Resident 2's room there was a communication board on top drawer of the resident's nightstand. The AA stated she provided Resident 2 with movies in Tagalog, and played Greek music for Resident 1. On 10/14/2020 at 12:23 p.m., during a concurrent record review of "Nursing Staffing Assignment and Sign-in Sheet", dated 9/23/2020, and interview with CNA 1 confirmed that he had worked on 9/23/2020. CNA 1 stated Resident 1 was transferred to a local hospital that day and was able to recall which bed Resident 1 was staying in. However, CNA 1 stated he was not sure why Resident 1 was transferred because he was on break. CNA 1 stated nurses cover each other for breaks and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BEWE11 Facility ID: CA940000069 If continuation sheet 8 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056014 (X3) DATE SURVEY COMPLETED 11/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKFIELD HEALTHCARE CENTER 9300 Telegraph Rd Downey, CA 90240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated CNA 4 was assigned to the rooms next to his on 9/23/2020. CNA 1 stated he usually took lunch break around 11:30 a.m. and that Resident 1 was in bed when he returned from his lunch break on 9/23/3030 but the resident was transferred to a local hospital after 3 p.m. CNA 1 stated Resident 1 spoke English and Greek, but mainly English. A review of the facility's "Nursing Staffing Assignment and Sign-in Sheet", dated 9/23/2020, indicated CNA 1 was assigned to care for Resident 1 from 7 a.m. to 3 p.m. On 10/14/2020 at 12:36 p.m., during an interview with Resident 1 (using the facility's interpreter service) stated the alleged incident in which the nurses hit him happened around noon time. Resident 1 stated he could not describe the nurses who hit him because they came from behind and did not see what they looked like. Resident 1 stated he did not tell his family member about the incident because he did not want to make them sad. On 11/17/2020 at 11:07 a.m., during an interview with Resident 1's Family Member (FM 1)stated Resident 1 spoke Greek and understood English, but could only speak some English. FM 1 stated Resident 1 took one back scratcher with him to the facility when he was admitted in 2018. On 11/17/2020 at 12:16 p.m., during an interview with Resident 3's FM 2 stated she currently worked at the facility as a physical therapy assistant. FM 2 stated Resident 3 spoke and understood some English but mainly simple phrases. FM 2 stated Resident 3 primarily spoke Tagalog and Bisaya. FM 2 stated staff used communication boards kept at residents' nightstands that contained cues for actions, such as for eating or using the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BEWE11 Facility ID: CA940000069 If continuation sheet 9 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056014 (X3) DATE SURVEY COMPLETED 11/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKFIELD HEALTHCARE CENTER 9300 Telegraph Rd Downey, CA 90240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE bathroom, to speak with residents who spoke another language. FM 2 stated Resident 3's communication board included Tagalog. FM 2 stated Resident 3 had difficulty understanding the communication board and staff so she translated for her. FM 2 stated there were other staff members who spoke Tagalog and an interpreter service was available at all times for translation. FM 2 could not recall the last inservice on using the interpreter service she attended but stated it was most likely within the last three months. FM 2 stated the DSD reminded staff of the resident's preferences and availability of the interpreter service during huddle every day, especially when there were new admissions. FM 2 stated the previous DSD also reminded staff on a daily basis. FM 2 stated Resident 3 had dementia and liked listening to music that she could dance to. On 11/19/2020 at 1:15 p.m., during a review of two of the facility's policies and procedures titled "Resident Rights, Translation" and "Quality of Care, Cognitive & Communication Assessment" (P&P) were the only P&Ps related to communication. On 11/20/2020 at 9 a.m., during an interview with the DSD stated the facility did not have any P&P for using interpreter services.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 12/03/2020 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BEWE11 Facility ID: CA940000069 If continuation sheet 10 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056014 (X3) DATE SURVEY COMPLETED 11/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKFIELD HEALTHCARE CENTER 9300 Telegraph Rd Downey, CA 90240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report a physical abuse allegation for one of 4 residents (1). Resident 1, alleged staff hit him in the groin area. The deficient practice had the potential to result in unidentified abuse in the facility and failure to protect Resident 1 and other residents from further abuse. Findings: On 10/08/2020 at 2:02 p.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BEWE11 Facility ID: CA940000069 If continuation sheet 11 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056014 (X3) DATE SURVEY COMPLETED 11/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKFIELD HEALTHCARE CENTER 9300 Telegraph Rd Downey, CA 90240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE interview with Certified Nursing Assistant (CNA 1) was asked the different types of abuse and stated the different abuses included verbal, physical, neglect, and isolation. CNA 1 referred to his badge and stated types of abuse included verbal, physical, mental, neglect, seclusion, and sexual. CNA 1 stated if the residents displayed behaviors such as attempting to fight, it needed to be reported to the charge nurse. CNA 1 could not recall the last abuse in-service he attended but stated it was offered about twice a year by the Director of Staff Development (DSD), Administrator (ADM), or Director of Nursing (DON). During interview CNA 1 stated the ADM was the facility's abuse coordinator. On 10/14/2020 at 1 p.m., during an interview with the DON stated local police were dispatched to the facility to interview the Assistant Director of Nursing (ADON) about a reported physical abuse allegation that was made by Resident 1. The DON stated afterwards the ADON called the local hospital to inquire about the alleged abuse but a Social Worker (SW) would not share any information. On 10/14/2020 at 1:17 p.m., during an interview with SW 1 stated Resident 1 told the triaging (determining degree of medical urgency) nurse in the emergency department at the local hospital about being allegedly hit in his private area while at the facility. According to SW 1 she further interviewed Resident 1 after the triaging nurse informed her of the alleged physical abuse allegation. During interview SW 1 stated Resident 1 told her a nurse had hit him in his private area with a back scratcher. SW 1 stated the day Resident 1 arrived to the emergency department she attempted to call the facility 22 times to inform them of the alleged physical abuse allegation but no one was answering and there was no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BEWE11 Facility ID: CA940000069 If continuation sheet 12 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056014 (X3) DATE SURVEY COMPLETED 11/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKFIELD HEALTHCARE CENTER 9300 Telegraph Rd Downey, CA 90240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE way to leave a message because the phone just kept ringing. SW 1 stated she eventually spoke with someone from Admissions and left her phone number but no one called back. On 11/18/2020 at 3:24 p.m., during an interview with the DON stated the ADON informed her that local police went to the facility to investigate an alleged physical abuse allegation on 10/07/2020 but did not share any information with the facility. The DON stated a Registered Nurse from a local hospital called the facility to inform them of the alleged physical abuse allegation made by Resident 1. The DON stated the ADON called the local hospital after police arrived to the facility and spoke with a SW who was not able to provide any information related to the alleged physical abuse allegation. The DON stated the facility did not report the abuse allegation to the State Survey Agency because it was not identified which resident was involved or where the incident occurred. The DON stated if someone alleges abuse at the facility it had to be reported to the ADM who was also the abuse coordinator so the investigation could be initiated. The DON stated any abuse allegations was reported to the ADM, the ombudsman, and the local police department. When asked if there was anyone else the abuse allegations was to be reported to the DON stated that she needed to check. The DON stated the timeframe to report abuse allegation was within two hours and that an investigative report needed to be conducted within 24 hours. The DON stated the ADON informed the ADM about the abuse allegation but was unsure as to when it was reported. On 11/18/2020 at 4:27 p.m., during an interview with the ADON stated on 10/07/2020 a local police officer went to the facility and informed her that he was following up on an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BEWE11 Facility ID: CA940000069 If continuation sheet 13 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056014 (X3) DATE SURVEY COMPLETED 11/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKFIELD HEALTHCARE CENTER 9300 Telegraph Rd Downey, CA 90240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE allegation of someone "touching" Resident 1's groin that was reported on 9/23/2020 from a local hospital. The ADON stated the police officer informed her he was not able to provide her with any details related to the abuse allegation. The ADON stated that on 10/07/2020 she called the local hospital and spoke with a SW who informed her that she could not disclose any information related to the abuse allegation. The ADON stated she spoke with Resident 1's Family Member (FM 1) to inform her of the abuse allegation as claimed by the local hospital. The ADON stated on 10/07/2020 she informed the ADM/abuse coordinator and the facility's SW about the alleged physical abuse allegation. However, the ADON stated she did not inform anyone else. The ADON stated any abuse allegations needed to be reported to the abuse coordinator, the local police department, the California Department of Public Health (CDPH), and the ombudsman immediately within two hours if there was bodily injury or within 24 hours if there was no bodily harm. The ADON discussed the abuse allegation with the ADM, DON, and facility SW who collectively determined there was "no known allegation of abuse" because the Resident 1 nor FM 1 reported it, and the hospital did not give details related to the abuse allegation. The ADON acknowledged and stated the facility did not report an abuse allegation on 10/07/2020. The ADON stated if there were any abuse allegations an investigation had to be started right away. The ADON stated "everyone" was a mandated reporter but the DON or SW completed the abuse report. On 11/19/2020 at 12:38 p.m., during an interview with the ADM stated he was the facility's abuse coordinator and was responsible for ensuring all the residents were free from any abuse. The ADM stated once FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BEWE11 Facility ID: CA940000069 If continuation sheet 14 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056014 (X3) DATE SURVEY COMPLETED 11/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKFIELD HEALTHCARE CENTER 9300 Telegraph Rd Downey, CA 90240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE being notified of any abuse allegations he ensured the victim and abuser were separated and were interview any persons involved including any witnesses. The ADM stated abuse allegations were immediately reported to the local police, ombudsman, and CDPH, and then an investigation of the abuse was initiated. The ADM stated the timeframe for abuse reporting was two hours and the facility had five days to complete an investigative report, either by himself or a designated person. The ADM stated no one had informed him of any abuse allegations for Resident 1. The ADM stated the ADON had informed him when the local police went to the facility to follow up on an abuse allegation as reported by a local hospital but was unable to recall when he was informed. The ADM stated the ADON had spoken with Resident 1 and FM 1 afterwards, who did not have any complaints. The ADM stated the ADON also called the local hospital and local police department to gather information but they did not have anything to report. The ADM stated no abuse allegation was reported to CDPH because the local police, local hospital, Resident 1, and FM 1 had nothing to report. The ADM stated he could not recall how soon the ADON had informed him of the abuse allegation after police visited the facility on 10/07/2020. The ADM again stated that he did not get information from anyone. A review of the facility's policy and procedure titled "Resident Rights, Abuse: Prevention of and Prohibition Against", not dated, indicated: "All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BEWE11 Facility ID: CA940000069 If continuation sheet 15 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056014 (X3) DATE SURVEY COMPLETED 11/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKFIELD HEALTHCARE CENTER 9300 Telegraph Rd Downey, CA 90240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: BEWE11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA940000069 (X5) COMPLETE DATE If continuation sheet 16 of 16