Brookdale Diablo Lodge

Pg 2 On 3/25/2024, R1, a known fall risk according to care plan dated 10/13/2023, had a fall in their room while attempting to change into their pajamas. S1 reported hearing R1 call for help and found them on the floor near their bed. S1 stated, “R1 said they lost their balance and fell. I usually remind them to press the pendant, but I didn’t see them before they fell.” S3 and S4 responded to the radio call and assisted R1. S4 reported that R1 said, “It hurts. It hurts. I fell,” and also, “Get me off this floor.” S1 and S4 helped R1 into a recliner, after which S4 called 911. Medical records obtained confirmed that R1 sustained a left hip fracture requiring surgical intervention. W1 expressed dissatisfaction with staff supervision and stated, “R1 had told me before that no one checked on them as much as they should. This isn’t the first time R1 has fallen, and it shouldn’t have happened.” R1 experienced multiple falls before 3/25/2024, including incidents on 8/7/2019, 1/1/2020, 1/15/2021, 6/11/2022 and 9/1/2023. Despite these incidents, the facility failed to revise R1’s care plan or implement additional safety measures. S1 stated, “I usually remind them to press the pendant.” S1 also reported that R1 would place their walker by the door, and that they typically checked on R1 four times per shift. S2 stated that R1 required help with showers, dressing, toileting, blood sugar checks, and escort assistance. S2 added, “R1 was changing into their pajamas when they fell and did not press their pendant for help.” Report Continues on LIC9099-C 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 Pg. 3 S3 confirmed that residents at risk of falling are required to be checked every 30 minutes, minimize environmental clutter, and use call pendant for assistance. S3 noted, “The facility does not have any real fall prevention methods in place for residents.” S3 added, “R1 began losing their balance but refused staff’s help. They had a walker but refused to use it and held onto rails in the facility for balance.” S4 reported that staff check call pendants monthly for functionality and all residents are expected to wear them 24/7. S4 stated, “The facility does not have other fall prevention equipment such as fall mats as not a lot of residents are considered a fall risk.” Interviews revealed that R1’s pendant was often left on their nightstand rather than worn or kept within reach. Incident reports for R1’s prior falls, including the fall on 1/15/2021, without follow-up details or documentation of corrective actions. Facility records provided did not show that R1s previous falls resulted in a reassessment of R1’s care needs or adjustment to their supervision. Staff, including S1 and S3, noted that R1 had become increasingly withdrawn in the month prior to the incident. S1 shared, “In the last month or so before R1 left the facility, they became very withdrawn, sad, and cried all the time. R1 told me that their son was sick.” However, there was no evidence of additional emotional support being provided, nor documentation of care planning to address R1’s reduced help-seeking behavior. Records and interviews overall did not have proactive, consistent strategies to mitigate R1’s known fall risk despite repeated incidents and observed decline. ****An immediate civil penalty of $500 is being assessed on today’s date. Civil penalty determination related to serious bodily injury is pending. **** Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.Exit interview conducted with Executive Director. A copy of this report and appeal rights was provided. 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 Pg. 2 On the allegation “Staff did not ensure reporting requirements were followed.” The fall involving R1 on 3/25/2024 was reported via LIC 624 to Community Care Licensing and documented in the facility’s records. Staff interviews confirmed that after the incident, notifications were made to R1’s physician, responsible party, and emergency services in accordance with regulatory requirements. Specifically, records show that R1’s physician was notified via facsimile at 20:00 hours, and their POA was contacted via telephone at 16:20 hours. Although the reporting party stated they were initially told that the incident had been reported to Licensing when it had not, the Department verified that a report was submitted by the facility within the appropriate timeframe. On the allegation “Staff did not ensure resident room was free from obstruction” The Department reviewed photographs of R1’s room submitted by W1 and conducted a review of the facility’s safety practices regarding environmental hazards. While W1 expressed concern regarding clutter in R1’s unit, staff interviews revealed that fall prevention strategies included reminders to reduce clutter and arrange furniture to allow for safe walkways. The Personal Service Plan dated 10/13/2023 stated, "Encourage R1 on reducing environmental clutter and arrange furniture for adequate walkways." Interviews with staff who responded to the fall did not indicate that obstructions or clutter directly caused or contributed to the incident on 3/25/2024. S3 stated that R1 was found close to their bed, and S4 confirmed that R1’s room did not appear to be cluttered during the response. Based on observations, photographs, interviews and file review the allegations above are unsubstantiated . Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted and copy of report provided.

On 11/05/2025 at 5:00 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a case management review related to complaint 15-AS-20240514173549. Upon arrival, LPA met with Executive Director, Rachel Davis, and explained the purpose of the visit. During the course of the investigation, The Department conducted interviews, and reviewed files. It was discovered R1 had several falls while at the facility occurring on 3/25/2024, 1/9/2023, and 6/10/2022 and that the facility did not update R1 care plan after subsequent falls to address R1’s change of condition and care needed. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING INVESTIGATION: Facility did not update residents care plan when there was a change in condition The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code. Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.

On 07/9/2025 at 8:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Rachael Davis and explained the purpose of the visit. The facility's fire clearance was approved for all may be non-ambulatory of which 8 may be bedridden. LPA toured the facility with Executive Director including but not limited to 6 residents apartments, bathrooms, activity room, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 73 degrees F. The hot water temperature in a sample of residents’ shared bathroom were measured between 105-120 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. The freezer temperature measured at 0 degrees F and the refrigerator 40 degrees F. Fire extinguisher was last serviced on 2/06/2025. Disaster Drill was last conducted 5/12/2025. Emergency Disaster plan last reviewed 4/21/2025. Smoke detectors and sprinklers are interconnected and observed throughout facility. First aid kit observed complete. LPA reviewed 6 staff records and 6 of 6 are associated and have current first-aid training. LPA reviewed 6 residents records and a sample of medications reviewed. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 08/07/24 at 5:50 PM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Executive Director, Rachael Davis and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature in random resident apartments was measured at 110.8, 113.2, and 109.4 degrees F. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility orders food supplies on a weekly basis. The freezer temperature measured at 0 degrees F and the refrigerator 36 degrees F. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 02/06/2024. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 07/19/2024 at 9:20 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Rachael Davis and explained the purpose of the visit. The facility's fire clearance was approved for all may be non-ambulatory of which 8 may be bedridden. LPA toured the facility with Executive Director including but not limited to 6 residents apartments, bathrooms, activity room, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 74 degrees F. The hot water temperature in a sample of residents’ shared bathroom were measured at 112.6, 109.2, 108.9 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. The freezer temperature measured at 0 degrees F and the refrigerator 36 degrees F. Fire extinguisher was last serviced on 2/06/2024. Disaster Drill was last conducted 7/18/2024. Emergency Disaster plan last reviewed 10/19/2023. Smoke detectors and sprinklers are interconnected and observed throughout facility. LPA reviewed 6 staff records and 6 of 6 are associated and have current first-aid training. LPA reviewed 5 residents records . No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

Allegation: Personal Rights - Staff did not address a resident change in medical condition However, based on interview with staff and W1, hospice was notified whenever staff observed a change in condition and nurse from hospice was requested by facility to assess resident. R1 was admitted to facility on January of 2022 and AGPA observed Personal Service Plan was updated, 3/4/22, and 8/22/2022 to address R1’s change in condition. Allegation: Personal Rights - Resident sustained injuries from multiple falls while in care Based on record review of incident report and progress notes, R1 had multiple unwitnessed falls on 1/28/22, 3/17/22, 8/12/22, and 8/14/22. However, no injuries were noted. R1 was admitted to ER on 3/17/22 and xray was completed, but no fractures were sustained from the fall. Allegation: Personal Rights - Staff did not follow a resident's care plan while in care Based on interview with W1, facility was following resident’s care plan and was in communication with hospice. W1 did not feel that there was any neglect by the facility according to the records from the nurses in charge during the time R1 was under hospice care. Allegation: Personal Rights - Staff did not properly report incidents involving a resident Based on record review, responsible party was notified of R1’s multiple falls that occurred on 1/28/22, 3/17/22, 8/12/22, and 8/14/22. Allegation: Personal Rights - Staff did not provide adequate care and supervision to a resident Based on record review, facility addressed the concern with R1’s responsible party regarding R1’s multiple falls. A care conference was held on 8/15/2022 where facility recommended a 1:1 companion for R1 due to increased agitation. However, R1’s responsible party refused. R1 was being checked by staff every 2 hours. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of report provided to Life Enrichment Manager. 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 Allegation: Personal Rights - Questionable Death The Department obtained a copy of R1’s death certificate where it indicates that the cause of death was due to chronic congestive heart failure and coronary artery disease. R1 was admitted to hospice on July 25, 2022 and was diagnosed with heart failure and not related due to neglect of the facility. This agency has investigated the complaint alleging questionable death. We have found that the complaint was UNFOUNDED , meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report provided to Life Enrichment Manager.

(...Continued from LIC9099) Facility elevator does not meet backup power requirements. Based on a review of regulations, facility records, and interview of ED the facility elevator does meet the existing backup power requirements. Staff did not follow emergency procedures during a power outage. Based on interviews of R1, ED, HWD, S1, S3, and facility records, staff did follow emergency procedures during the power outage of 07/01/2023. Staff not trained on emergency procedures during a power outage. Based on interviews of ED, HWD, S1, S3, and facility records, staff was trained extensively on emergency procedures. Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report emailed to ED.

It was alleged the temperature was below the regulated limit. Based on observation, each apartments have its own air conditioner and heating. On 12/6/2021, S1 stated resident's apartments are equipped with smart thermostat where the temperature is set between 65 degrees F and 81 degrees F, but most rooms are set at 72 degrees F. S1 stated if residents are not able to set their own thermostat, residents will call concierge to have staff set temperature for residents. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided to Executive Director.

On 1/19/2023 starting at 3:30 PM, Licensing Program Analysts (LPAs) L. Francisco and P. Watson conducted a Health & Safety inspection as a result of a Priority 1 complaint. LPAs met with Executive Director, Rachael Davis and explained the purpose of the visit. LPAs toured facility including but not limited to the random apartments, bathrooms, common areas, and kitchen. A sample of hot water temperature were maintained at 114, 115.1, and 113.8 degrees F in random residents apartments. LPAs observed an adequate one week of non-perishable and 2-day of perishable food supply. Resident's medications were kept locked in the medication cart. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be fullt charged and last serviced on 8/10/2022. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING HEALTH & SAFETY INSPECTION At 3:30 PM, LPAs observed unlocked cleaning supplies, bug spray, and bleach inside kitchen cabinet and bathroom cabinets in R1's apartment At 3:36 PM, LPAs observed unlocked gardening tools, oxyclean, and comet. The following deficiency was observed (see LICd 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided to Executive Director.

On 7/28/2021 at 11:05am, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct Infection Control Inspection. LPA met with Executive Director, Bill Grady and Business Office Manager, Rachel Davis and explained the purpose of this visit.. During the Infection Control Inspection, LPA toured facility with Executive Director and Business Office Manager including but not limited to front entrance, screening station, hand washing stations, apartments, common areas, kitchen and courtyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Facility staff were observed to be wearing proper PPE. LPA observed 30-day supply of PPEs and accessible to staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.