336426512-8-4-2021-18-AS-EMAN-C6AUK2-20210827153826

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426512
Report Date: 08/02/2021
Date Signed: 08/04/2021 09:34:51 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/04/2020 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200204142402

FACILITY NAME:	BROOKDALE RANCHO MIRAGE		FACILITY NUMBER:	336426512
ADMINISTRATOR:	BARTON, ROBERT		FACILITY TYPE:	741
ADDRESS:	72201 COUNTRY CLUB DR		TELEPHONE:	(760) 340-5999
CITY:	RANCHO MIRAGE	STATE: CA	ZIP CODE:	92270
CAPACITY:	0	CENSUS: 0	DATE:	08/02/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Andrew Lindner		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Lack of staff supervision resulted in resident sustaining serious injury.
Staff did not seek medical treatment for resident in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Williams conducted a tele-conference in order to deliver findings for the above allegations. A tele-conference was conducted due to the facility's closure since 6/01/2021. LPA spoke with Facility Representative, Andrew Lindner, to discuss the purpose of the call. The Department investigation included records review and interviews with staff, residents, and witnesses.

In regards to allegation #1, Department staff interviewed facility staff which revealed that Resident #1 (R1) sustained an unwitnessed fall on 8/16/19 and two unwitnessed falls on 8/18/19. When interviewed about R1, facility staff stated that R1 had a history of falls and were aware that R1 was a fall risk and in need of one-on-one supervision. However, during the course of the investigation, it was found that one-on-one supervision was not provided as needed for R1. R1 was receiving hospice services since 8/15/19 and it was found during investigation that prior to hospice services, R1 had shown a change in condition, including a decrease in cognitive abilities and abilities to assist with daily care. At the time of R1's hospice admission, it was noted that R1 had been “very weak and tired” and required “maximum assistance” with activities of daily living. R1 was

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 18-AS-20200204142402

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROOKDALE RANCHO MIRAGE	FACILITY NUMBER: 336426512
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/03/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	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... sufficient support staff shall be employed to ensure provision of personal assistance and care. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	An Immediate Civil Penalty of $500.00 was assessed for violation that the Department determined resulted in the injury or illness of a person in care.
	8 9 10 11 12 13 14	Based on records review and interviews, the licensee did not ensure that facility personnel were sufficient in numbers and/or competent to provide the services necessary to meet resident needs. Facility staff failed to properly supervise R1, who was known to be a fall risk, resulting in R1 sustaining a broken femur.	8 9 10 11 12 13 14
Type A 08/03/2021 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs ...This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The facility's representative agreed to send the Department a letter of understanding of the violation.
	8 9 10 11 12 13 14	Based on records review and interviews, the licensee did not ensure that (R1) was regularly observed for changed in condition. R1 experienced multiple falls and change in condition; however, facility staff failed to seek timely medical care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20200204142402

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROOKDALE RANCHO MIRAGE	FACILITY NUMBER: 336426512
	VISIT DATE: 08/02/2021

NARRATIVE

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reported to be non-ambulatory and required use of a wheelchair. As further indicated in hospice records, R1 was “very high risk for falls” due to “mentation, impulsiveness to get up, weakness,” and history of falls.

Based on the evidence found during the course of the investigation, there was corroborating evidence to support the allegation that lack of facility staff supervision of R1 resulted in R1 sustaining serious injury; therefore, the allegation is substantiated. Facility staff supervision was not provided as needed on at least 8/16/19 and 8/18/19 when R1 fell. On 8/20/19, R1 was sent to the hospital after facility staff observed R1 to be grimacing in pain and moaning when incontinent care was being provided. According to review of medical records, R1 was admitted to the hospital and diagnosed with a “closed fracture of left hip, initial encounter; fall.”

In regards to allegation #2, records for R1 indicate that R1 was unable to make needs known. Department staff found that R1 fell once on 8/16/19 and twice on 8/18/19. Based on records review and interviews, it was found that around 7:30 PM on 8/16/19, R1 was observed on the facility hallway floor. Two days later at around 8:30 AM on 8/18/19, facility staff documented that R1 was very agitated and needed to be given anxiety medication. This was change in condition for R1, as R1 was known to be “cooperative” for all care provided. At around 4:10 PM, on 8/18/19, R1 was found in a sitting position on the facility's hallway floor. The time of the second fall on 8/18/19 was not documented in facility records, although staff acknowledged that R1 did have two falls on 8/18/19. During the course of the investigation, it was found that facility staff did not seek medical attention for R1 following these multiple falls and apparent change in condition. It was not until around 11:30 PM on 8/19/19 that staff sought medical care for R1, when R1 was observed to be grimacing in pain and moaning when incontinent care was being provided by facility staff. According to R1's medical records, R1 was admitted to the hospital after midnight on 8/20/19 and subsequently diagnosed with “closed fracture of left hip, initial encounter; fall.” As a result of investigation completed, allegation that facility staff failed to seek timely medical care for R1 is substantiated.

A substantiated finding means that the allegation is valid because the preponderance of the evidence standard has been met. In addition, allegation #1, lack of staff supervision resulted in resident sustaining serious injury, posed an immediate health and safety risk to residents in care. An Immediate Civil Penalty of $500 is being assessed. The facility representative was also informed that civil penalty may be assessed based on Health and Safety Code 1569.49(f).

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 18-AS-20200204142402

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROOKDALE RANCHO MIRAGE	FACILITY NUMBER: 336426512
	VISIT DATE: 08/02/2021

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	An exit interview was conducted where this report (LIC 9099, LIC9099C & LIC9099D) was discussed. A copy of this report and appeal rights were sent to the facility representative via email to retrieve signatures.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4