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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005467
Report Date: 07/22/2024
Date Signed: 07/22/2024 04:59:09 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
04/08/2024 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240408112425
FACILITY NAME:BROOKDALE FOLSOMFACILITY NUMBER:
347005467
ADMINISTRATOR:KRISTINE CLAWSONFACILITY TYPE:
740
ADDRESS:780 HARRINGTON WAYTELEPHONE:
(916) 983-9300
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:130CENSUS: 89DATE:
07/22/2024
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Shari Kanig, Executive Director TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff left resident in soiled briefs for extended period of time.
Staff did not meet resident’s care needs.
Staff are not sufficiently trained.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver investigative findings to a complaint received on 4/8/24. LPA met with receptionist who stated the Administrator was temporarily unavailable and allowed LPA to complete today's report in the private dining room. LPA met with the Administrator, Shari Kranig, later during today's inspection.

In April and May 2024, the Department interviewed the Administrator, the Resident Care Coordinator, multiple facility staff ("am" and "pm" shifts), hospice personnel (2) and resident’s family member. The Department reviewed documentation pertaining to resident (R1), including hospice care notes, physician's report, care plan, and staff training records.

The results of the investigation are as follows:

cont on 9099C-1...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
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 8
Control Number 59-AS-20240408112425
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: BROOKDALE FOLSOM
FACILITY NUMBER: 347005467
VISIT DATE: 07/22/2024
NARRATIVE
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9099C-1.. Allegation: Staff left resident in soiled briefs for extended period of time. The allegation states resident (R1) has been found in heavily urine soaked briefs, on several occasions, and (R1) had to have been left in soiled briefs for at least four hours. The allegation states caregiver states that R1 wouldn’t let them change (R1).

Resident's (R1) physician reports (9/14/22) states resident has a diagnosis of Dementia. (R1's) care plan, dated 3/22/24, notes that (R1) demonstrates anxious, disruptive or obsessive behaviors, and hospice notes indicate (R1) began receiving hospice care in December 2023.

All facility staff interviews revealed resident (R1) can be resistant to care. The Administrator, at the time, stated multiple approaches have been tried to get (R1) to do care with staff. The Resident Care Coordinator (RCC) stated (R1) is "checked every 2 hours but there are times when she is physically aggressive with staff and staff has to leave the resident alone", explaining (R1) will "push and scream", mostly when she is being changed, so staff will return in 10 minutes and try to provide the care again. The RCC commented that after 2-3 attempts, staff can try PRN Lorazepam- sometimes (R1) will take it and it works, but if she doesn't take it, it takes 2-3 caregivers to change her.

One lead staff stated (R1) is very particular with receiving assistance with Activities of Daily Living (ADL's) and about not being touched, adding (R1) has "soaked through her Depends" as she "will refuse toileting at least once a week". Two additional staff stated it takes two staff to change (R1's) diaper or clothes, or get her in the shower, as (R1) is "combative and will try to hold (keep) her pants on". One of the staff stated they will notify the Med-Tech if a resident won't let staff change them, and staff will try again in 10 minutes, stating "putting things on is not the problem- it's taking them off".

One staff stated she has had to remind care staff to change (R1) before and when hospice visits (R1), stating she feels it is a combination of staff not attending to residents and being tired as some staff are working "double shifts and 6 days/week", adding "things get busy but we try to change residents every 1-2 hours". Interviews revealed (R1) is "totally incontinent now" since December 2023 and "won't even go in the bathroom now without screaming".

*cont on 9099C-2...

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 59-AS-20240408112425
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: BROOKDALE FOLSOM
FACILITY NUMBER: 347005467
VISIT DATE: 07/22/2024
NARRATIVE
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9099C-2...An outside care provider stated "it's hard to tell if it's neglect or if the resident is refusing care, explaining "(R1) can get combative and needs two staff to change her". This staff indicated that sometimes (R1) is "Very wet or soiled" but it's difficult to know if staff may be "trying to avoid confrontation" since (R1)has behaviors.

Resident's family member stated in May 2024 that hospice staff has "been frustrated with the care", explaining, (R1's) rash started around Mar/April 2024 and hospice staff told facility staff to check (R1) "more often".

Hospice records show that on 2/2/24 (5:45 pm), when (R1) was seen for wound care, resident was found in urine “soaked diaper” and was changed by the hospice nurse since there was not an available caregiver. Hospice notes indicate (R1) was somewhat resistant to the care provided.

Additional hospice notes indicate that on 3/19/24- (9:00 am), the hospice nurse arrived and found resident with a saturated diaper, and on 4/5/24 (3:00 pm), the nurse arrived and found resident with both a saturated diaper and wet pants. Staff was instructed verbally to change resident's diaper frequently to prevent skin breakdown and a Urinary Tract Infection (UTI) and verbalized their understanding.

In May 2024, a hospice nurse stated staff has been doing a better job than in previous months, and (R1), is "not laying 6 hours in a diaper", stating she has visited at different times and on different days (i.e. 7:30 am and 6:00 pm on weekends and week days) and they know what day she's coming back for the next visit.



A second hospice staff stated she sometimes finds (R1) where she hasn't been changed timely, stating she is also concerned that (R'1s) clothing, or at least her top, is "not being changed daily", adding it's important since the elderly can "shred dry skin".

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.


*cont on 9099C-3..
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 59-AS-20240408112425
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: BROOKDALE FOLSOM
FACILITY NUMBER: 347005467
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/24/2024
Section Cited
CCR
87625(b)(3)
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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:
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Licensee/Administrator agree to ....
conduct training with all staff on 7/24/24 (Wed) regarding incontinent care. A separate all staff training will be scheduled with Memory Care staff on 7/31/24.
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Based on hospice records reviewed, the Licensee did not ensure that resident (R1) was kept clean and dry, on 2/2/24, 3/19/24, 4/5/24, and on 4/26/24, when hospice was at the facility to see (R1), which posed an immediate health and safety risk to residents in care.
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Documentation to be submitted by 8/12/24.
Type A
07/24/2024
Section Cited
CCR
87464(f)(4)
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87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed 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. This requirement is not met as evidenced by:

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Licensee/Administrator agree to ....
conduct training with all staff on 7/24/24 and a separate training with all Memory Care Staff on 7/31/24.
Documentation to be submitted by 8/12/24
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Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R1) was provided with the personal assistance and care in ensuring her compression socks were worn as ordered, shoes and feet were kept clean on 4/5/24 and 4/6/24, and Seroquel medication was given as ordered, which posed an immediate health and safety risk to residents in care.
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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 SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 59-AS-20240408112425
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: BROOKDALE FOLSOM
FACILITY NUMBER: 347005467
VISIT DATE: 07/22/2024
NARRATIVE
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9099C-3.. Allegation: Staff did not meet resident’s care needs. Complaint alleges on 4/5/24, R1 was observed to not be wearing compression stockings, and when (R1's) slip-on-shoes were removed, it was observed that (R1’s) left foot was covered in dry feces. On 4/6/24, Home Health/Hospice Aide. found dried feces in R1’s shoes again.

1- Hospice notes document that (R1) was not found wearing compression socks on the following days: 2/21/24, 2/25/24, 3/3/24, 3/19/24,4/15/24, and on 4/26/24 when the hospice nurse visited. Hospice records show (R1) was wearing the compression socks on 4/9/24.

On 4/10/24, LPA Angela Hood observed (R1) to appear to be clean and to be wearing compression socks. LPA confirmed (R1) received a bath earlier that day, in the morning. LPA toured (R1's) room and observed a sign posted, dated 11/22/23, reminding staff to not forget to put R1's socks on in the morning and take them off in the evening. On 5/23/24, LPA Calzada observed (R1) to be wearing a pair of compression socks (black), along with clean, dry clothes, and her hair to appear clean and styled. When touring resident's room, LPA asked to see extra pairs of compression socks but staff was not able to locate a pair. LPA observed a sign posted above (R1's)dresser instructing staff to "put compression stockings on every morning and remove every night". LPA was not able to observe if (R1) was wearing compression socks on 7/22/24 as LPA was informed that (R1) had passed on 6/20/24.


Staff interviews revealed that (R1) had multiple pairs of compression socks, but staff lost one pair, and the socks possibly disappeared in the laundry. A Med-Tech stated how staff is supposed to put the socks on every day, but there are still times when (R1) is not wearing them at the right times, due to her refusing to let staff take them off, and she will sometimes kick and scream when being changed, indicating medication changes have been made a few times to assist with behaviors. A caregiver stated staff will take the socks off after the shower, during the "pm" shift and it's possible they were left off after the shower and one pair was missing and (R1) "also hides stuff, and would hoard napkins and spoons".

Staff stated, in May 2024, compression socks are part of (R1's) care plan and the Memory Care Director printed out (R1's) care plan and told staff a month ago they need to follow the care plan of putting the socks on in the morning and taking them off at bedtime.

A hospice staff stated, in May 2024, that staff have been better about putting the compression socks on regularly, and she is not concerned with any other residents, stating (R1's) "behaviors are why she is difficult". *cont on 9099C-4..

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 59-AS-20240408112425
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: BROOKDALE FOLSOM
FACILITY NUMBER: 347005467
VISIT DATE: 07/22/2024
NARRATIVE
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9099C-4...2- Hospice records document that on 4/5/24 (3:00 pm), when the nurwse removed R1’s slip on shoes, she found the bottom of (R1’s) left foot covered in dry feces.

A second hospice staff confirmed that on 4/6/24, she found dried feces on one of the insoles of a pair of (R1's) shoes and that she observed this during the "pm" shift, and staff tried to blame it on other shift person. This staff confirmed resident's shoes were washed right after feces was noticed on 4/6/24.

One caregiver staff stated that she was not aware of dried feces being found in (R1's) shoes, but that it's possible this may have happened as (R1) sometimes has "standing accidents" and has a "lose bottom" (or diarrhea) and or urine leak. This staff stated (R1's) shoes are washed "often", but that it's possible an accident occurred one time, and it was not caught by staff.

3-On 3/21/24, hospice records note that resident (R1) had missed several “pm” doses of Seroquel on: 3/12, 3/15 and 3/20, and several “am” doses of Seroquel on 3/12, 3/15, 3/18 and 3/20. Hospice notes indicate that a Med-Tech stated the medications were missed due to (R1) falling asleep. Notes document that the Hospice nurse left instructions that the "pm" dosage of Seroquel needs to be given before bed, as prescribed and the “am” dose needs to be at or after breakfast.


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.




*cont on 90099C-5...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 59-AS-20240408112425
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: BROOKDALE FOLSOM
FACILITY NUMBER: 347005467
VISIT DATE: 07/22/2024
NARRATIVE
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9099C-5... Allegation: Staff are not sufficiently trained. The complaint alleges that staff are not trained to work with clients with Dementia and resident (R1) needs to wear compression socks but staff do not place them on R1. In March 2024, when the compression stockings were not on R1, caregiver (S1) initially stated she didn’t know where they were, but after the socks were found, stated they were too hard to place on (R1).

Staff were interviewed about training received. One Med-Tech stated that when staff are first hired, they spend the first 3 shifts (8 hrs/each or 24 hrs) completing approved on-line training before working on the floor with residents. This staff stated the Business Office Director manages staff training.

One caregiver stated she completed on-line training and 2 weeks of shadowing, including "reverse shadowing" which is a "good process". This staff stated all caregivers are now trained this way and it's "helpful", and she feels all staff is "pretty well trained" and also receives monthly in-service training. Another caregiver stated that after she was hired, she shadowed staff and then "they shadowed me”, and she does not believe staff need additional training, asserting, "No, everyone has the same amount of training- it's who puts in the effort".



The Resident Care Coordinator was asked if staff is trained to handle behaviors related to Dementia and stated "absolutely- some newer staff can call management or the Med-Tech if they have a difficult person". RCC confirmed new staff complete on-line training and then complete 3-4 days of shadowing, and the Business Office Director monitors the on-line training completed by staff.

Staff training records for (14) staff were provided in April 2024. Review of the records showed that staff (S1) and multiple other staff had completed the required initial training hours but had not always completed the required training for each year thereafter.

Based on records reviewed, 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.

There are (3) deficiencies issued on the 9099-D pages.
Exit interview. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 59-AS-20240408112425
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: BROOKDALE FOLSOM
FACILITY NUMBER: 347005467
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2024
Section Cited
HSC
1569.625
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§1569.625 Staff training; legislative findings; contents (b)(2) (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
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Licensee/Administrator agree to review all staff training records to ensure that all staff have completed both initial and continuing yearly training, as required per the HSC 1569.625.
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Based on review of (14) staff training records, provided in April 2024, many of the staff, including (S1), did not complete the required annual training, specifically to Dementia care, following the initial year of employment, which poses a potential health and safety risk to residents in care.
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Documentation is due to the Department by 8/12/24.

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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 SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8