347001289-7-24-2024-59-AS-MSEY-D7PSCF-20240731134529

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001289
Report Date: 07/24/2024
Date Signed: 07/24/2024 03:58:40 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2024 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240409145013

FACILITY NAME:	ELDERLY INN I, THE		FACILITY NUMBER:	347001289
ADMINISTRATOR:	TOPLEAN, DANIELA		FACILITY TYPE:	740
ADDRESS:	5206 ROBERTSON AVENUE		TELEPHONE:	(916) 488-4518
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 3	DATE:	07/24/2024
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Robert Tif, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident was left on the floor unassisted after sustaining a fall for an extended period of time due to staff neglect.
Staff do not provide resident adequate supervision resulting in resident wandering outside.
Staff do not ensure that resident's incontinence needs are being met.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver complaint findings to a complaint received on 4/9/24. LPA met with caregiver, Icolyn "Sonia" Powell who called Administrator, Robert Tif, who arrived at 2:55 pm. LPA observed (1) resident watching television in the common area. Sonia indicated there are (2) caregivers at the related home across the driveway and (1) caregiver is shared between both facilities when needed.

During the course of the investigation, the Department reviewed documentation related to resident (R1) including the physician's report, care plan, facility notes, hospice care notes and photos. Interviews were conducted with multiple facility staff, hospice staff and resident's family member. The results of the investigation are as follows:

Resident (R1) moved to the care home on 3/5/24. Resident's pre-appraisal notes that (R1) appears weak, is unable to walk safety, does not have a diagnosis of Dementia, but nurses stated resident is confused and disoriented, as he has attempted to leave the previous facility before. Resident's physician's report (2/15/24) states (R1) has diagnoses of Metabolic Encephalopathy and Dementia, is incontinent, confused, disoriented but able to follow simple directions, is a fall risk, has some aggressive behavior with pulling catheter out, needs extensive assistance with bathing, dressing, toileting and medications and cannot leave the care home unassisted. *cont on 9099C-1..

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

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 7

Control Number 59-AS-20240409145013

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ELDERLY INN I, THE	FACILITY NUMBER: 347001289
	VISIT DATE: 07/24/2024

NARRATIVE

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9099C-1.. Resident's care plan, dated 3/5/24, notes says resident is “weak and confused” and “planned an escape from previous facility before arriving”. Care plan says resident has a “history of confusion and wants to leave, having some outbursts”. Watch resident and work with hospice if he has any outbursts.

Allegation: Resident was left on the floor unassisted after sustaining a fall for an extended period of time due to staff neglect. Allegation states resident (R1) was left on the floor after falling for more than 2 hours, on 3/19/24.

Administrator, Robert Tif, stated on 4/10/24 to LPA Angela Hood that (R1) slid off the bed and refused to get up , didn't want staff to assist, and he wanted to stay on the floor, stating resident was cooperative only at times. Resident facility notes indicate that on 3/19/24, resident slid down from his bed and refused help from (3) caregivers.

Caregiver (S1) stated she "checked on (R1) at 7:00 am, and he was still sleeping" but by 9:00 am, he was on the floor, asserting, "he did not fall- he slid off his bed". (S1) stated that she and another staff were trying to get (R1) up from the floor, but "we couldn't get him up- he was kicking staff". (S1) stated that even hospice nurses couldn't provide care for (R1) and one night, the nurse was at the care home until midnight observing (R1')s behaviors and was unable to provide care at some times. Hospice notes show the nurse stayed for (6) hours on 3/19/24, from 6:00 pm until 12:00 am, observing resident and administering a new medication.

Another staff (S2), who worked during the day, was interviewed but stated she was not at this facility at the time of this incident, but that another care staff, went to assist (S1) from the adjacent related facility, with (R1). (S2) indicated she no longer works at the care homes.

Hospice notes document on 3/19/24 (12:06 pm)- a Home Health Aide (HHA) from hospice arrived and resident was “found on the ground, bleeding on the right arm and covered in urine”. Notes stated care staff indicated (R1) had been on the floor since the morning, the HHA and the caregiver were able to put (R1) back in bed, but (R1) was observed to have redness on right hip, new skin tears, and a missing a toe nail. (R1's) condition was reported to an Registered Nurse, who would provide follow up care later that day. Hospice notes document that (R1) received a complete bed bath and ADL care.
*cont on 9099C-2...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 59-AS-20240409145013

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ELDERLY INN I, THE	FACILITY NUMBER: 347001289
	VISIT DATE: 07/24/2024

NARRATIVE

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9099C2... Three (3) photos were viewed that were taken by hospice on 3/19/24 (12:06 pm) showing (R1) on the floor. One photo shows (R1)laying on the floor in his room with blood near the right arm where he was laying. Clothes appear soaked, and hospice notes say resident was "soaked in urine". The photo shows resident's catheter attached laying on the floor. The second photo shows (R1) was found wearing a soiled diaper when the nurse arrived. The third photo shows redness on (R1's) right hip, as stated in hospice notes.

Hospice notes show that on 3/19/24 (2:15 pm) a nurse arrived to provide catheter care and (R1) became very agitated and would not let go of the nurse's wrist for a couple of minutes. The nurse obtained a physician's order for the medication Haldol. Notes show that another nurse arrived on 3/19/24 (3:15 pm) to administer Haldol and monitor resident who was displaying restlessness, agitation, and episodes of hallucinations. A continuous care nurse arrived around 6:00 pm to continue monitoring (R1), who continued to show agitation, disorientation and attempts to stand up. Another dose of medication was given around 7:00 pm, and again at 11:00 pm, before (R1) relaxed and went to sleep, at which time the nurse left.

Both the resident's family member and hospice stated the facility did not call them, and they were not aware of (R1) being on the floor, for over 2 hours, until the hospice home health aide arrived for a scheduled appointment to provide assistance with Activities of Daily Living (ADL's).

Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Allegation: Staff do not provide resident adequate supervision resulting in resident wandering outside. The allegation states resident (R1) had to be retrieved from outdoors unaccompanied at night, and was found in the garage, without any clothes on on another occasion.

Staff (S1) stated she found (R1) around 9:00 am, "squatting in the garage with a diaper on only", and she has "no idea" how long (R1) was in the garage. (S1) confirmed that the large garage door was open and that she "doesn't know how it opened or how (R1) got to the garage". (S1) confirmed she brought (R1) into the house upon discovering him there and it was only one time he was found in the garage. Staff (S2) stated she remembers when (R1) was found in the garage one morning and stated "he always wanted to leave, especially when his daughter visited- he would get agitated sometimes". *cont on 9099C-3..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 7

Control Number 59-AS-20240409145013

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ELDERLY INN I, THE	FACILITY NUMBER: 347001289
	VISIT DATE: 07/24/2024

NARRATIVE

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9099C-3... Resident's family member stated she was called following when (R1) was found in the garage on the morning of 3/15/24, and his "arms were torn up, he was naked and his catheter was torn out". The family member stated (S1) called hospice upon finding (R1) in the garage and hospice came out and observed wounds from his wrist to his elbow that were "bad" and had to be wrapped completely. Resident's family member stated (S1) showed her a picture she had taken of (R1) sitting on blankets by the laundry machine in the garage.

Hospice notes from 3/15/24 (10:09 am) state the hospice RN received a phone call from the facility needing a nurse to come by, and upon the nurse’s arrival, the caregiver stated (R1) was found sleeping in the garage, with no clothes on, and (R1) had disconnected catheter bag again and there was blood to both arms from skin trauma (picking scabs). Notes state that (R1) allowed the nurse to perform wound care while being “confused and drowsy”.

Also included in the hospice notes, is that (R1) was allowed to depart from an unlocked door in his bedroom, and the owner was contacted and advised that “dead bolt must be locked to prevent injury/escape by resident who is highly confused”. A new Seroquel prescription arrived and was administered.

The facility Administrator stated on 7/24/24 that the current door alarm was on the exit door from (R1's) room but he is not sure if it was working to alert the NOC shift. LPA observed the alarm on the door today to not be activated, but the room is currently vacant.

Facility notes document that on 3/9/24- (R1) “got up on his feet by himself- caregivers surprised he can walk so well”. Notes document on 3/10/24 (R1) had wandered from his room and was found in the living room by caregivers. Notes entered on 3/11/24, stated that (R1) was doing "more wandering" in his room and bed alarms were placed in his room to better monitor him. Notes entered on 3/13/24, state (R1) is more calm, seems to be getting acclimated to home and getting a little stronger. There was no time of day indicated in the notes for the above days.

Facility notes document on 3/14/24, (R1) wandered into the garage at 5:00 am, was brought back to his room, and family was called. On 3/15/24, no notes were made that resident was found on the floor in the garage, with only a brief on and multiple bleeding wounds on the arms.

*cont on 9099C-4...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 59-AS-20240409145013

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ELDERLY INN I, THE	FACILITY NUMBER: 347001289
	VISIT DATE: 07/24/2024

NARRATIVE

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9099C-4... Resident's family member stated that she recalls from her conversations with both facility and hospice staff, that (R1) was able to make his way to the garage on two separate occasions and stated, "It was too much for one caregiver to handle (R1) and the other residents- (R1) needed more attention and needed to be checked on more frequently".

Staff (S3) who works during the night shift (7 pm- 7 am) was not available for an interview.

Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Allegation: Staff do not ensure that resident's incontinence needs are being met. Allegation states resident (R1) was left in soiled briefs for prolonged periods.

The Administrator confirmed "yes, we tried to change him- sometimes he would be cooperative and sometimes he would not" and (R1) had a catheter that hospice was providing care for.

Hospice notes on 3/15/24 (9:42 pm) document the on-call nurse received a call from the facility that "no urine had drained into patient's collection bag since it was replaced on this morning". Both hospice staff and (R1's) family member stated that caregivers were informed to notify hospice if there is no urine output within 2-4 hours of the bag being changed.

Hospice care notes entered on 3/19-(12:06 pm) by a Home Health aide, document (R1) was “found on the ground, bleeding on the right arm and covered in urine”. Care staff stated (R1) had been on the floor since the morning. The Department reviewed a photo showing the soiled diaper (R1) that was found wearing during this HHA's scheduled visit, on 3/19/24, to provide ADL care. A hospice nurse confirmed the soiled diaper shown in the photo was not blood or urine, but feces. Also provided was second photo showing (R1) laying on the floor in his room, with soiled clothing and the catheter bag and tubing on the floor. Hospice notes match the photos provided.

Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (3) deficiencies are issued on the 9099-D pages. Exit interview. Copy of report and appeal rights provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 59-AS-20240409145013

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ELDERLY INN I, THE	FACILITY NUMBER: 347001289
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/25/2024 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to read the regulation and stated it isunderstood and to also conduct staff training on proper incontinent care. Documentation of training due by 7/25/24
	8 9 10 11 12 13 14	Based on interviews conducted and documentation reviewed, the License/Administrator did not ensure that resident's (R1) hospice company was contacted promptly after resident was found on the floor, on 3/19/24 (around 9:00am), bleeding and soaked in urine, which posed an immediate health and safety risk to residents in care. Hospice was made aware when they arrived on 3/19/24 (12:00 pm) for a scheduled appointment with resident, and after (R1) had been laying on the floor for 2+ hours.	8 9 10 11 12 13 14	Documentation of completed training by 8/8/24 for current staff. The deadline can be extended for any new staff.
Type A 07/25/2024 Section Cited CCR 87705(c)(4)(A)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(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. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to read the regulation and stated it isunderstood and to also conduct staff training on proper incontinent care. Documentation of training due by 7/25/24.
	8 9 10 11 12 13 14	Based on documentation reviewed and interviews conducted, the Licensee/Administrator did not ensure that a staff member was alerted when resident (R1) woke up and walked to the garage on 3/14/24 and on 3/15/24, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Documentation of completed training by 8/8/24 for current staff. The deadline can be extended for any new staff.

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: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 59-AS-20240409145013

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ELDERLY INN I, THE	FACILITY NUMBER: 347001289
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/25/2024 Section Cited CCR 87625(b)(3)	1 2 3 4 5 6 7	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 is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to read the regulation and stated it isunderstood and to also conduct staff training on proper incontinent care. Documentation of training due by 7/25/24.
	8 9 10 11 12 13 14	Based on documentation reviewed from hospice, the Licensee/Administrator did not ensure that resident's (R1's) hospice company was notifiied on 3/15/24, within 4 hours of resident not showing any urine output, and on 3/19/24, when resident was found laying in a soiled diaper and urine soaked clothing and had been on the floor for at least 2 hours, which posed an immediate health and safety risk to residents in care.b	8 9 10 11 12 13 14	Documentation of completed training by 8/8/24 for current staff. The deadline can be extended for any new staff.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 7