Summerset Lincoln Assisted Living and Memory Care

Allegation investigated: Staff did not meet resident's hygiene needs. Unqualified staff administered insulin shots to residents. Staff falsified residents' medication records. Resident sustained an unwitnessed fall resulting in a fracture.

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Tuesday October 10, 2023, to complete and deliver findings to a complaint received on 4/6/2023. LPA met with Administrator Mark and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, current and previous staff. LPA interviewed R1’s POA regarding the allegations. LPA reviewed R1’s file at the facility including physicians report, nursing notes, MARs, hospital discharge paperwork, physician’s orders, and employee notes regarding R1’s POA behavior to staff. The result of the investigation is as follows: Per staff interviews, S1 worked as the resident services director. At this time, the facility scheduled nurses for 12-hour shifts. Per interviews, there were no nurses scheduled for 7 days per week. According to the allegation, S1 would conduct blood sugar checks and give R2 their insulin. S2, who is a registered nurse, would then sign the MAR. According to State records, S1 obtained their nursing license on 7/14/2022. Substantiated Previous staff interviews acknowledge witnessing S1 provide insulin injections prior to obtaining their license. Interviews from previous and current staff acknowledged that R1 needed assistance with bathing, dressing, grooming, and incontinence care. Interviews stated that R1’s was incontinent of bladder and bowel. Staff stated that, for most of R1’s stay at the facility, R1’s POA refused to provide proper incontinence products for R1. Therefore, when R1 would become incontinent, this required a change of clothing. Additionally, staff stated that it was difficult for R1 to comply with incontinence care. Nursing notes also detail R1’s refusal for showers. Interviews and nursing notes detail repeated times where R1 was observed walking without their walker. Nursing notes also detail staff attempts to have R1 use their walker. Nursing notes also detailed R1 would refuse to use their glasses or leave them in other resident apartments. R1’s physicians report indicated that they had motor impairment/paralysis and needed to use a walker to prevent falls. Additionally, R1 had a history of seizures which led to additional falls. Therefore, due to R1’s history of seizures and falls, along with wandering behavior, the facility failed to provide proper supervision. Additionally, R1’s care plan was not updated as required based on level of care. Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D. Appeal rights were printed and given. Exit interview conducted. A copy of this report was left at the facility. LPA reviewed R1’s MARs. Additionally, based on staff interviews and documentation review, LPA learned that R1 would often refuse medication. LPA reviewed communication between the facility and R1's primary physician. Nursing notes stated that R1 would become aggressive and refuse to take their medication. LPA interviewed previous and current staff who stated that R1’s had a history of agitation and being aggressive. R1 would constantly walk the hallways of the facility. LPA reviewed R1’s nursing notes which detail, at times, R1 was exit seeking. R1 had a history of going in other resident apartments and taking their items. No staff interviews revealed that R1 was being harassed by another resident. R1 had several roommates while living at the facility. Interviews acknowledged that, due to cognitive impairment of the residents, R1 and their roommate would create messes in the room. Staff stated that they tried to keep resident items organized and belongings separated. Staff interviews stated that throughout R1’s stay at the facility, there were times when the facility was short of staff due to call-ins. LPA was unable to obtain staffing schedules due to the amount of time that had passed and management turnover. Staff interviews stated that R1 was offered hydration at meals, and in between meals. Additionally, R1 had a hydration bottle. Per staff interviews, R1 would often leave the hydration bottle while walking the hallways, pour the water out, or refuse to drink. Interviews stated that R1 was constantly walking the hallways. At times, it was difficult to get R1 to sit. Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, Exit interview. A copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 59-AS-20230406113411

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: Oct 11, 2023

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. . . This requirement was not met as evidenced by R1 having a Dx of seizures and having repeated falls and wandering. This poses a direct threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: Administrator to submit plan regarding 1:1 and eviction procedures for residents who require additonal care and supervision outside of normal staffing.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87629(b)(1) · Plan of correction due date: Oct 11, 2023

87629 Injections (b) . . . the licensees who admit or retain residents who require injections shall be responsible for the following: (1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement was not met as evidenced by allowing an employee who did not have their nursing license administer insulin injections. This poses a direct threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: Administrator to submit nursing schedule including back-up plan if schedule nurse calls off.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Oct 27, 2023

87625 Managed Incontinence (b) . . .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 was not met as evidenced by R1 having repeated incontinence in clothing documented by nursing notes and photographs. This poses an indirect threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: Administrator to submit proof of training regarding incontinence care and cleanliness.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Oct 27, 2023

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by S2 signing the MAR regarding R2's insulin when they were not the one to administer the injection. This poses an indirect threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: Administrator to submit proof of training for care staff regarding documentation.

Allegation investigated: Staff grabbing resident arm and screaming in resident face. Staff failed to change resident.

LPA Parks arrived on Thursday September 28, 2023, to conclude a complaint investigation regarding the above allegations. LPA met with Administrator Mark and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, previous and current facility staff. LPA reviewed R1’s file including physicians report, care plan, and progress notes. Based on interviews, no staff acknowledged having witnessed or heard about staff grabbing resident’s arm or screaming in their face. Additionally, there was no documentation of this occurring in resident’s file. Based on documentation review and staff interviews, R1 had a history of behaviors and, at times, was resistant to care. Based on staff interviews, R1 would, at times, refuse incontinence care. LPA was unable to verify R1’s shower schedule, only that they required one person assist. R1's progress notes detail R1's refusal of care, including incontinence care. Unsubstantiated Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, Exit interview. A copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Sep 28, 2023 · control 25-AS-20230117164126

Allegation investigated: Facility is not adhering to Covid-19 masking protocols. Facility is not adhering to Covid-19 quarantining/isolation protocols. Facility is not adhering to Covid-19 testing protocols. Facility does not provide staff with adequate PPE.

LPA Parks arrived on Thursday September 28, 2023, to conclude a complaint investigation regarding the above allegations. LPA met with Administrator Mark and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator and facility staff. LPA reviewed the facility’s Infection Control Plan. Additionally, at the time the complaint was filed, LPA conducted a facility walk-through. The result of the investigation is as follows. Throughout the facility walk-though, LPA observed (and took photos) of PPE supply. Facility has cases of N95 masks, surgical masks, gloves, gowns, and face shields. LPA also observed cases of covid-tests. LPA observed PPE carts in the hallway of covid positive residents. LPA observed cases of individual bottles of hand sanitizer and large hand sanitizer stations (in the hallway and mounted on the wall). LPA observed covid positive residents to be quarantined in their apartments, as much as possible, in a memory care unit. LPA observed staff wearing PPE when entering covid positive apartments. Unsubstantiated LPA obtained an updated copy of the covid positive and covid negative residents. Per the facility, all residents will be retested in two days. LPA interviewed staff who stated they had access to full PPE to provide care for covid positive residents. Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, Exit interview. A copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Sep 28, 2023 · control 59-AS-20230310160924

Allegation investigated: Facility staff did not properly monitor resident's catheter Facility staff are not properly supervising residents who may be a fall risk Facility staff did not seek timely medical attention for resident

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday June 15, 2023, to complete and deliver findings to a complaint received on 11/22/2022. LPA met with Administrator Mark and explained purpose of visit. Throughout the course of the investigation, LPA interviewed staff including the Administrator, nurses, med techs, and caregivers. LPA reviewed R1’s file at the facility including physicians report, progress notes, MARS (September, October, November), and a record of falls. Additionally, LPA interviewed R1’s home health company which provided skilled care for R1’s catheter. The result of the investigation is as follows: Based on notes on R1’s MAR, they were out of the facility for the following times: Sept 20 – 21, Oct 13 – Oct 22, Oct 31 – Nov 1, Nov 4 – Nov 5, Nov 9 – Nov 10, and Nov 12 – Nov 22. Additionally, based on progress notes and documented faxes to R1’s primary physicians, R1 fell on the following Substantiated dates: 10/2, 10/6, 10/9, 10/13, 10/24, 11/5, and 11/9. R1’s fall on 11/9, resulted in a fractured shoulder and laceration on their head. Progress notes on 10/31, state that there was no catheter output for all of NOC shift. There is no documentation that R1’s family or physician was notified. R1 was later sent to the hospital where their hospital records note that more than 854 mL was drained. R1 was followed by Freedom Home Health, who had provided them with regular nurse visits. While the facility was responsible for draining the catheter, any medical interventions related to the catheter was provided by Freedom Home Health. However, because a catheter is considered a restricted health condition, the facility was required to provide training for all staff regarding R1 and their catheter care. There is no documented evidence that the facility staff were provided this training. Based on the information detailed above, LPA finds that both these allegations are substantiated. A finding that the allegations are Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Due to R1's fall which resulted in a fractured shoulder, a $500 civil penalty for serious bodily injury will be issued. This civil penalty will be issued at a later date due to technical issues. Deficiencies cited on 9099-D. Appeal rights were printed and given. Exit interview conducted. A copy of this report was left at the facility. Based on LPAs interviews and review of documentation, the preponderance of evidence standards was not met, therefore, the above allegation is found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted. A copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jun 15, 2023 · control 25-AS-20221122121630

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jun 19, 2023

Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical. . . . the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person. This requirement was not met as evidenced by R1's POA and doctor not being notified of their catheter not draining. This poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jun 15, 2023

Plan of correction: Facility to begin training for all staff regarding observation of resident requirements. Facility to complete by send LPA proof of training by end of day 6/19/2023.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(e) · Plan of correction due date: Jun 16, 2023

Basic services requirements (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement was not met as evidenced by R1 sustaining multiple falls. This poses a direct risk to the health and safety of resident in care.the state’s words, verbatim · CDSS document, Jun 15, 2023

Plan of correction: Administrator agreed to submit a memo of understading regarding upholding the admission agreement by implementing a 1:1 when a resident is a danger to themselves or someone else.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87623 · Plan of correction due date: Jun 29, 2023

87623 Indwelling Urinary Catheter (B) There shall be written documentation by an appropriately skilled professional outlining the instruction of the procedures delegated and the names of the facility staff who have been instructed. This requirement was not met as evidenced by no documentation of staff training related to R1 and their catheter care. This poses an indirect threat to the health and safety of resident in care.the state’s words, verbatim · CDSS document, Jun 15, 2023

Plan of correction: The administrator agreed to submit a memo of understanding regarding the regulation.

Allegation investigated: Facility did not safeguard resident belongings Facility staff physically abused resident in care Facility failed to report Resident was not given medication as prescribed

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday June 15, 2023, to complete and deliver findings to a complaint received on 1/11/2023. LPA met with Administrator Mark and explained purpose of visit. Throughout the course of the investigation, LPA interviewed the Administrator, Business Office Director, previous memory care director, current and previous staff. LPA reviewed R1’s file at the facility including physicians report, progress notes, MARs from March – December 2022, LIC621, LIC500, personal service plan, preplacement appraisal and medication orders and communication with physicians. The result of the investigation is as follows: LPA interviewed Business Office Director who stated that on 12/7/2022, it was reported to the Memory Care Director, at the time, that S1 witnessed S2 hitting R1. While S2 was being interviewed, they acknowledged that they grabbed R1’s hands and held them down. S2 suspended and later terminated. The facility acknowledged that there was not a SOC341 Substantiated and/or LIC624 completed and sent to the appropriate agencies. LPA reviewed all Medication Administration Records while the R1 resided at the facility. LPA also reviewed all orders for R1 regarding the medication Seroquel. LPA observed 10 signed orders for this medication. LPA observed that the medication orders in the MAR matched the signed orders. However, there were no signatures for this medication on the following dates 9/6, 9/8, 9/21, 9/22, 9/23, 9/27, 10/6, 10/14, 10/30, 10/26, 11/4 (twice), 11/8, 11/10, 11/16. There were no records indicating a reason as to why the medication was not given. The Administrator acknowledged that R1’s prescription glasses and lower dentures were missing. Per the Administrator, he asked R1’s family to provide two estimates to replace the missing denture. However, R1’s family only produced one estimate approximately $8,000. Based on the information detailed above, LPA finds the allegations are substantiated. A finding that the allegations are Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D. Appeal rights were printed and given. Exit interview conducted. A copy of this report was left at the facility. ‘collected and taken by family to the lab’ dated 11/5/2022. However, progress notes and interviews conducted did not reveal R1 exhibited symptoms of a UTI that went untreated. Due to the information above, LPA finds the allegation to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Administrator, copy of report was provided via email.the state’s words, verbatim · CDSS document, Jun 15, 2023 · control 25-AS-20230111151017

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87468.1(a)(3) · Plan of correction due date: Jun 16, 2023

Personal Rights of Residents in All Facilities (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidence by S2 forcefully grabbing R1's hands while performing ADLs. This poses an immediate risk to the health and safety of resident in care.the state’s words, verbatim · CDSS document, Jun 15, 2023

Plan of correction: Administrator agrees submit proof scheduled training regarding resident rights for staff.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Jun 16, 2023

Incidental Medical and Dental Care The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:based on interview and MAR document review, resident was not given medication as prescribed. This poses a direct risk to the health and safety of resident in care.the state’s words, verbatim · CDSS document, Jun 15, 2023

Plan of correction: Administrator to schedule a training regarding medication requirements.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 16, 2023

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports . . (1) A written report shall be submitted to the licensing agency at (D) Any incident which threatens the welfare, safety or health of any resident . . . This requirement was not met as evidnced by no SOC341 or LIC624 submitted to the Ombudsman or Licensing. This poses a potential risk to the health and safety of resident in care.the state’s words, verbatim · CDSS document, Jun 15, 2023

Plan of correction: Administrator to schedule training with management regarding reporting requirements.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a)(2) · Plan of correction due date: Jun 29, 2023

Theft and Loss (2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. . . This requirement was not met as evidenced by R1's glasses and lower dentures were lost and R1's POA has not received reimbursement for the items. This poses a potential risk to the health and safety of resident in care.the state’s words, verbatim · CDSS document, Jun 15, 2023

Plan of correction: Administrator agreed to work with the family to come to an agreement regarding replacing dentures while there is an open balance of over $5,000 on R1's account.

Allegation investigated: Facility staff failed to monitor resident's water and food intake resulting in hospitalization

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Tuesday June 6, 2023, to complete and deliver findings to a complaint received on 2/14/2023. LPA met with Administrator Mark and explained purpose of visit. LPA interviewed the Administrator and facility staff including nurses, med techs, caregivers, and activity staff. Med tech (S1) acknowledged they contacted the physician and POA regarding R1’s decline. S2, S3, and S4 stated that they offered snacks and hydration to R1. LPA reviewed R1’s file including the physicians report and assessment. The physicians report which was signed by a physician on 1/6/2023, stated that R1 had the capacity to feed themselves. Additionally, the facility assessment dated 1/7/2023, stated that R1 was independent for meals and did not require meal reminders. Due to the information above, LPA finds the allegation to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Administrator, copy of report was provided via email. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 6, 2023 · control 25-AS-20230214091816

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff do not distribute resident's medications as prescribed

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday June 1, 2023 to complete and deliver findings to a complaint received on 3/15/2023. LPA met with Administrator Mark and explained purpose of visit. LPA interviewed the Administrator and facility staff including nurses, med techs, and residents. Med techs acknowledged that they have an hour before and an hour the prescribed time to give medications to residents. Staff stated there have not been times (during AM and PM shift) where one med tech works both floors independently. Due to the complaint allegation not stating specific incidents, residents, dates, or staff, LPA was unable to further investigate. Due to the information above, LPA finds the allegation to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Administrator, copy of report was provided via email. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 1, 2023 · control 59-AS-20230315134023

Allegation investigated: Resident is being inappropriately restrained while in care Resident was not properly assessed before residing in the facility Staff are not providing access to a resident's personal belongings

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday May 11, 2023 to complete and deliver findings to a complaint received on 1/19/2023. LPA met with Administrator Mark and explained purpose of visit. LPA interviewed the Administrator and facility staff including Business Office Manager, Receptionist, Nurses, and caregivers. LPA reviewed resident’s file including physicians report, assessment, care plan, and power of attorney paperwork. The results of the investigation is as follows: R1 moved into the facility on January 7, 2023. In R1’s file, the personal service plan assessment was completed by an LVN and dated 1/7/2023. The assessment detailed that staff would be responsible for monitoring R1’s behaviors including aggression, agitation, and exit seeking. Per the assessment, the facility would also be responsible for the following care: status checks, redirecting, bathing, grooming reminders, toileting, laundry, and medication management. R1’s physicians report states that R1 has a Unfounded primary diagnosis of Parkinson’s Disease with a secondary diagnosis of Dementia. R1 is not able to leave the facility unassisted. Staff interviews acknowledged that R1 followed a friend out of the facility, as they were leaving, but was able to be redirected back inside of the facility. Interviews with staff revealed that R1 required redirecting but was generally complaint. Additionally, interviews with staff revealed that R1’s family member was asking several staff for copies of R1’s file and power of attorney paperwork. All staff stated that they informed the family member that they were unable to release this information without consent of the power of attorney. Staff interviewed stated that R1 never asked for this paperwork. Based on information obtained, LPA finds the allegations to be UNFOUNDED- means that the allegations are false, could not have happened, and/or are without a reasonable basis. Exit interview. A copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, May 11, 2023 · control 25-AS-20230119123543

Allegation investigated: Resident lost severe weight while in care Staff mismanaged resident’s medication

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday May 11, 2023 to complete and deliver findings to a complaint received on 4/6/2023. LPA met with Administrator Mark and explained purpose of visit. LPA interviewed the Administrator and facility staff including Marketing Director, Facility Nurses, Caregivers, med techs, R1’s Nurse Practitioner, wife and daughter. LPA reviewed resident’s file including physicians report, assessment, care plan, medication list, MARs, and PRN authorization form. The results of the investigation is as follows: LPA reviewed R1’s assessment which stated that R1 required total assistance for meals. R1’s weight upon move-in on February 20, 2023 was 162 pounds. R1 visited his primary physician and weighed 148 pounds on 3/24/2023. Additionally, R1’s MAR noted that R1’s weight was recorded as 142 on 4/3/2023 by staff. R1’s primary physician was contacted on 2/24/2023 regarding R1’s agitation and confusion, there is no record of the physician being contacted regarding weight loss. Substantiated Upon move-in, R1 was prescribed three medications. One medication, Trazadone, had an order that was routine and as needed (PRN). On 3/24/2023, R1’s primary physician wrote a discontinue order for the Trazadone. At the facility, the routine Trazadone was discontinued, however the PRN order maintained. LPA clarified with R1’s primary physician who stated that her discontinue order was for both routine and PRN. Additionally, the PRN Trazadone order stated to give ½ tablet (25mg) to 1 tablet (50mg) by mouth at bedtime as needed for insomnia. R1’s MAR shows that the PRN Trazadone was given 8 times in March and once in April. Furthermore, R1’s PRN authorization form stated, as filled out by R1’s physician, that ‘My patient cannot determine his/her need for prescription and/or nonprescription PRN medication and cannot communicate his/her symptoms indicating a need for a nonprescription medication’. This form continues to state that ‘If your patient cannot determine his/her need for a medication or clearly communicate the symptoms for a nonprescription medication, then you, the physician, must be contacted before the PRN medication can be given’. There was no documentation or communication produced that shows the facility contacted the physician prior to giving the PRN medication to R1. Based on the information detailed above, LPA finds that both these allegations are substantiated. A finding that the allegations are Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D. Appeal rights were printed and given. Exit interview conducted. A copy of this report was left at the facility. R1’s chart notes that he would, at times, refuse medications. Staff interviewed stated that he would sometimes refuse assistance with activities of daily living (ADLs). Staff interviewed stated that R1 would become agitated and verbally combative. Staff interviewed stated that R1 was constantly walking in the hallways and common areas. All staff acknowledged that there were daily, repeated attempts during mealtimes, redirecting when exit seeking/wandering, and repeated attempts for ADLs. Based on information obtained during the investigation, LPA finds the allegation to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, Exit interview. A copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, May 11, 2023 · control 59-AS-20230406152123

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: May 12, 2023

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes. . . changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.This requirement was not met as evidenced by no communication between the facility and R1 regarding R1’s weight loss. This poses a direct threat to the health and safety of resident in care.the state’s words, verbatim · CDSS document, May 11, 2023

Plan of correction: Administrator to meet with management 5/12/2023, in the morning. Administrator to schedule training with med techs, nurses, and floor staff on 5/22/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(d)(1) · Plan of correction due date: May 12, 2023

Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, (1) Facility staff shall contact the resident's physician prior to each dose This requirement was not met as evidenced by no communication with R1’s physician prior to dispensing the PRN medication to R1. This poses a direct threat to the health and safety of resident in care.the state’s words, verbatim · CDSS document, May 11, 2023

Plan of correction: Administrator to assign facility staff to review all PRN authorization forms and ensure that med techs are following signed order. Facility to ensure complaince by 5/22/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e)(2) · Plan of correction due date: May 12, 2023

Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication . . . physician's order and the label shall contain at least all of the following information (2) The exact dosage.This requirement was not met as evidenced by R1’s PRN medication stating to take ½ tablet (25mg) to 1 tablet (50mg) by mouth as needed for insomnia. This poses a direct threat to the health and safety of resident in care.the state’s words, verbatim · CDSS document, May 11, 2023

Plan of correction: Administrator to submit plan by POC due date. Administrator to assigned staff to reveiw all MARS and ensure prescription label complaince by 5/22/2023.

Type of visit: Required - 1 Year

LPA Parks arrived on Tuesday January 17, 2023 to conduct the annual inspection. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. LPA was screened by employee at the front desk of the facility. LPA and Administrator completed the infection control domain together and facility was found to be in substantial compliance at this time. LPA and Administrator toured facility together to ensure health and safety of residents in care. In the areas toured, no immediate health, safety, or personal rights violations were observed. Facility has a supply of more than 30 days of full PPE. LPA requested updated copies of LIC500, LIC610 and current liability insurance by end of month. No deficiencies are being cited as a result of todays inspection. Exit interview conducted. A copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jan 17, 2023

Allegation investigated: Neglect/ lack of care and supervision resulted in resident sustaining fractures Staff neglect resident while in care Staff failed to provide a comfortable temperature for resident in care Staff failed to respond to resident’s call assistance button in a timely manner Resident sustained multiple UTIs while in care Facility has insufficient staffing to meet residents’ needs Staff failed to make sure resident was hydrated Staff mismanaged resident’s medication Staff overcharged resident and Staff failed to keep resident's room clean

LPA Parks arrived on Tuesday October 25, 2022 to conclude a complaint investigation regarding the following allegations: neglect/lack of care and supervision resulted in resident sustaining fractures, staff neglect to resident while in care, staff failed to provide a comfortable temperature for resident in care, staff failed to respond to resident's call assistance button in a timely manner, resident sustained multiple UTIs while in care, facility has insufficient staffing to meet residents' needs, staff failed to make sure resident was hydrated, staff mismanaged resident's medication, staff overcharged resident, and staff failed to keep resident's room clean. Prior to the visit, LPA completed the required COVID-19 testing protocols and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Unfounded Throughout the course of the investigation, LPA reviewed the following documentation: R1's physicians report, medication administration record (MAR), hospital discharge paperwork, care notes, medication list, and admission agreement. Additionally, LPA reviewed a restraining order in place for R1. LPA interviewed the following relevant parties: facility staff including management, activities director, housekeeping, caregivers, and med techs. Based on the review of documentation and interviews conducted, LPA concluded the following: the facility staffing is sufficient to meet the resident's needs. If there are staff who call in sick, management will find a replacement. Therefore, R1 has not experienced neglect due to staffing issues. Additionally, while R1 has a history of falls and UTIs, this was not due to facility staffing. All staff interviewed acknowledge that R1's room is kept neat and orderly. R1's thermostat is kept at a reasonable temperature. Additionally, R1 can vocalize to staff if she wishes her thermostat to be adjusted. All staff acknowledge that R1 spends the majority of her day in the common area, amongst activities staff and caregivers. Staff perform frequent checks on her throughout the day and night. LPA was unable to find any medication errors with R1's MAR. Per documentation reviewed, facility is following doctors orders in regards to medication. LPA learned that the facility is offering fluids to R1 appropriately. R1 is offered a variety of liquid throughout the day including coffee, water, and juice (3 meals plus 2 snack times each day). Additionally, R1 has a water bottle in her room to assist with hydration. Based on LPAs interviews and review of documentation, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted. A copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 25, 2022 · control 25-AS-20220322162547

Allegation investigated: - Blood sugar checks are being administered by someone who is not a skilled professional. - G-Tube feedings are being administered by someone who is not a skilled professional.

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 08/23/2022 to deliver complaint findings for a complaint Community Care Licensing (CCL) received on 03/07/2022. LPA met with Administrator, Mark Morris, and explained the purpose of the visit. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility. Throughout the course of the complaint investigation, the Department conducted interviews and obtained pertinent documents, such as resident’s (R1) physician's report, needs and services plan, emergency contact, G-Tube doctor’s order, and approved exception request for prohibited health condition from the Department. Continue on page LIC-9099C. Unsubstantiated Allegation: Blood sugar checks are being administered by someone who is not a skilled professional. – Unsubstantiated. According to Complainant, an unlicensed nursing student working at the facility as a Resident Care Director (RCD) is assisting R1 with blood sugar checks. Interview statement received from Memory Care Director, Denise Landgraf, indicated there are a total of four (4) residents on insulin and one (1) resident that needs assistance with blood sugar checks. MCD stated only nurses are assisting residents with blood sugar checks. MCD stated she started working at the facility on 06/01/2022 and, shortly after, RCD got licensed and was officially a nurse. Interview statement from ED indicated that, during the time the complaint was opened, RCD was a student nurse and working while Sabrina Boyle was the ED. ED was also working at the facility at the time Sabrina Boyle was the ED. ED stated he observed RCD shadowing Sabrina Boyle but was not performing any blood sugar checks on residents. Interview statement received from staff member (S1) indicated that S1 has not observed RCD assisting residents with blood sugar checks. Interview statement received from staff member (S2) revealed that S2 had observed RCD assisting a resident with blood sugar checks. S2 indicated that RCD is a nurse and is allowed to assist with blood sugar checks. On 03/09/2022, LPA interviewed RCD, who denied assisting a resident with blood sugar checks. RCD also denied being a Licensed Vocational Nurse at the time of the interview. According to Board of Vocational Nursing and Psychiatric Technicians DCA search, RCD is a Licensed Vocational Nurse with an issuance date of 07/14/2022. Allegation: G-Tube feedings are being administered by someone who is not a skilled professional. – Unsubstantiated. According to Complainant, Resident Care Director (RCD) who is a nursing student without a license is assisting R1 with G-Tube feedings. R1’s physician report states R1’s primary diagnosis is diabetes. R1 has a Laryngectomy tube. On 03/29/2022, the Department had granted an exception request for the prohibited health condition of G-Tube care for R1. Terms and conditions include: the licensee will monitor, document, and ensure that all routine feeding, hydration, medication administration through the G-Tube and stoma cleaning are provided by a licensed skilled professional due to the resident's inability to perform tasks on their own. The licensee will ensure and document that staff responsible for the care of this resident will be trained by the licensed skilled professional for G-Tube feeding, hydration and stoma cleaning. For routine medications, staff will be trained by the skilled nursing professional per physician's orders as to administration procedure. This training is in addition to other required regulatory training and must be documented and maintained on file. The licensee will ensure that a skilled professional is maintaining oversight of all aspects of care for the G-Tube and training of staff assigned to this resident. Training shall be updated no less than once every 6 months. All training, procedures, protocols and other physician and skilled professional notes shall be maintained on file at the facility. According to R1’s needs and services plan, R1 does not need assistance with Laryngectomy tube and self manages Laryngeal tube. R1 can suction and clean Laryngeal tube. Nursing staff will stand by as R1 cleans tube as ordered daily to make sure proper care is being done. Facility staff will monitor for signs and symptoms of infection or complications and notify medical doctor. Facility staff will observe and prompt R1 with Laryngeal tube care and suctioning. The Department conducted interviews with a total of six (6) facility staff. Interview statements received from S1 and S2 were consistent with one another. S1 and S2 indicated that facility’s Licensed Vocational Nurses (LVNs) are the only ones to assist residents with prohibited health conditions, such as G-tube care. Interview statement received from MCD revealed that the facility always has a nurse working in the building. MCD stated that, if MCD is off and a nurse is not on-site or nowhere to be found in the community, the facility will call MCD to come in. MCD stated that, when they were hired for this position, management had gone over expectations with MCD. The management’s expectations are that MCD is to be on call and come to the facility when needed. Interview with ED revealed that there is always a nurse working in the building and, if there is ever a situation where there are no nurses in the building, the facility would use on-call nurses or have the nurse at the community next door (Summerset Lincoln Assisting Living) to assist. LPA interviewed RSD, who denied assisting resident with G-tube feeding. Due to the information above, LPA finds the allegations to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Executive Director, copy of report was provided via email.the state’s words, verbatim · CDSS document, Aug 23, 2022 · control 25-AS-20220307105102

Allegation investigated: Staff are locking residents' doors from the outside

Licensing Program Analyst (LPA) Jacob Williams arrived at the facility and met with Mark Morris, Executive Director, to open a complaint investigation into the allegation listed above. LPA wore an N-95 mask and was screened by facility upon entry. Facility staff wore masks while on the premises. During today’s visit, LPA conducted an interview with Executive Director. Based on information obtained, LPA finds the above allegation to be UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies being cited per Title 22 Regulations, Division 6, Chapter 8. Exit interview conducted. Exit interview conducted and a copy of this report is being provided to the Executive Director. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 6, 2022 · control 25-AS-20220526123404

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Williams arrived on Thursday March 24, 2022 to conduct the annual inspection. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. LPA and Maintenance Director, Mark Morris, toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: kitchen, outdoor patio, laundry rooms, bedrooms (4) and bathrooms (5). In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Maintenance Director completed the infection control domain together and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of todays inspection. Exit interview conducted. A copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 24, 2022

Allegation investigated: Facility is not following proper COVID-19 mask guidance.

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 3/9/2022 to conduct a Complaint Investigation. LPA met with Executive Director (ED), Jo Ann Franklin, and explained the purpose of the visit. Prior to initiating the complaint inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA observed five (5) staff working in the facilirt at time of visit. Of those staff, neither were wearing masks. PIN 20-22-ASC issued on 2/7/2022 states All ASC residential facilities must strictly adhere to current CDPH Masking Gudiance: Masks are required for all individuals in the following indoor setting regardless of vaccination status: Long Term Care Settings & Adult and Senior Care Facilities. Substantiated Based on information obtained, the Department finds the portion of the allegation pertaining to clients 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. Based on California Code of Regulation, Title 22, Division & Chapter 8, one (1) deficiency is being cited. Appeal Rights provided. Exit interview conducted with ED.the state’s words, verbatim · CDSS document, Mar 9, 2022 · control 25-AS-20220302094927

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80072(a)(2) · Plan of correction due date: Mar 16, 2022

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observation of staff, the facility staff are not wearing masks while inside of the facility, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 9, 2022

Plan of correction: Executive Director agrees to conduct in- service for all staff. ED is to review PIN 20-22-ASC and submit to CCL in writing that PIN was reviewed. Proof of in-service and review of PIN is to be submitted by POC due date, 3/16/2022.

Type of visit: Case Management - Other

LPA Lusby arrived on Friday October 21, 2021 to conduct a case management visit. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. The purpose of this visit was to verify that S1 was no longer employed and no longer associated to the facility. Administrator Sabrina confirmed S1's termination on 10/19/2020 and that S1 has not been in the facility since. No deficiency observed. Exit interview conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Oct 22, 2021

Type of visit: Required - 1 Year

LPA Lusby arrived on Wednesday September 8, 2021 to conduct the annual inspection. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. LPA was screened by staff at the front desk of the facility. LPA, Memory Care Director Shannon Hargis, and Resident Services Director Stephanie Broadnax toured the facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, hallways, and memory care (2nd floor). In the areas toured, no immediate health, safety, or personal rights violations were observed. Facility has a supply of more than 30 days of full PPE. LPA and Administrator Zahra completed the infection control domain together via telephone and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of todays inspection. Exit interview conducted. A copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 8, 2021