Aldersly

At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with and Wellness Nurse, Melanie Fenn. During the course of the investigation, LPA requested and reviewed documents, conducted interviews, and made observations. LPA investigated the following allegations, “Personal Rights, Reporting Requirements, Facility did not follow COVID protocols during an outbreak, and Lack of Staffing resulting in resident falls.” “Personal Rights” – Complainant alleged that facility staff shove and push Resident 1 (R1) and other residents to get them to go somewhere. Complainant also alleged that R1 has poor hygiene because R1 has been observed with food on their face before and after meals and has been observed with dirty hands/nails and wearing dirty/stained clothes. Review of R1’s Functional Assessment dated 03/21/2024 indicated that Continued on LIC9099C UnsubstantiatedRead the full finding— CDSS inspection report, July 1, 2025 · control 21-AS-20250109161946

At approximately 10:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Executive Director/Administrator, Shannon Brown, and Health and Wellness Nurse, Melanie Fenn. During the course of the investigation, LPA Felias requested and reviewed documents, conducted interviews, and made observations. There is an allegation that Facility failed to meet resident's care needs. Reporting Party alleges that facility did not meet Resident 1’s (R1’s) care needs by not showering R1, not providing incontinence care to R1, and not giving R1 their suppository medication. Reporting Party also alleges that the lack of care resulted in R1 contracting sepsis from a urinary tract infection resulting in hospitalization. LPA conducted interviews with involved individuals. Per interviews, LPA was informed that a care conference meeting was conducted with the facility to address concerns regarding R1’s care. ContinueRead the full finding— CDSS inspection report, February 29, 2024 · control 21-AS-20231115131419

Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Administrator Shannon Brown to deliver findings regarding the complaint allegation above. Regarding allegation Staff did not follow resident’s feeding plan. Per Reporting Party, on 12/29/2022 it was noticed that there was a full food tray wrapped up sitting next to resident (R1) who had difficulty swallowing and was on a feeding plan where they were to be given soft or liquid foods because R1 had difficulty swallowing and was supposed to be provided assistance with eating. Also, Reporting Party noticed that there was a care plan taped over R1's bed dated 11/10/22, with a different resident’s name. Based on confidential interviews conducted with facility staff on 4/6/23, it was revealed that their normal meal process is to provide residents with their meal tray that has their name on it, then they will leave them for residents to eat it and staff will return about an hour later to remove the tray. Per stRead the full finding— CDSS inspection report, April 21, 2023 · control 21-AS-20230126084215

At approximately 9:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to initiate a complaint investigation regarding the above allegation and met with Executive Director/Administrator, Shannon Brown, and Charge Nurse, Melanie Fenn. There is an allegation that Staff are not providing resident’s files to resident’s authorized representative. Based on records reviewed and interviews conducted, LPA observed that Resident 1 (R1) resided in the Independent Living area of the facility. Community Care Licensing (CCL) does not have jurisdiction to enforce regulations on that portion of the facility. LPA was unable to identify any deficiencies on the Assisted Living (AL) side of the facility where CCL does have jurisdiction. The allegation that staff are not providing resident’s files to resident’s authorized representative is UNFOUNDED. An allegation that is UNFOUNDED, means that the allegation was false, could not have happened and/or is without a reasonable basis. NoRead the full finding— CDSS inspection report, March 9, 2023 · control 21-AS-20230302111949

At approximately 10:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with Executive Director, Shannon Brown, and Charge Nurse, Melanie Fenn. During the course of the investigation, LPA Felias reviewed and requested documents, made observations at the facility, and conducted interviews. There is an allegation of Neglect/Lack of supervision resulting in resident sustaining unexplained injuries. Based on information provided to LPA, the unexplained injury was described as a “gash” on Resident 1’s (R1) scalp and bruising on their cheek. Review of Facility documents during the alleged timeframe of injury did not show any written documentation of a gash being observed on R1’s scalp. Review of R1’s Physician Report dated 10/04/2018, indicated that R1 does not have dementia and can communicate their needs. Based resident interviews conducted, LPA received inconsistent information regardingRead the full finding— CDSS inspection report, February 7, 2023 · control 21-AS-20221007124556

At approximately 11:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for the Complaint Investigation regarding the above allegations and met with Executive Director, Shannon Brown, and Charge Nurse, Melanie Fenn. During the course of the investigation, LPA Felias reviewed and requested documents, made observations at the facility, and conducted interviews. There is an allegation that Staff do not provide enough liquids to resident in care. Interview conducted with Resident 1 (R1) stated that facility offers snacks and drinks to them. Other resident interviews conducted stated that staff offer drinks frequently. During visit conducted 2/7/2023, LPA observed a sign showing that staff offer snacks and drinks every day at 3:30PM. Based on observations made and interviews conducted, the LPA is unable to determine if staff do not provide enough liquids to resident in care. Therefore, this allegation is Unsubstantiated. Continued on LIC9099C UnsubstantiatedRead the full finding— CDSS inspection report, February 7, 2023 · control 21-AS-20221025151918