Summerset Lincoln Assisted Living And Memory Care

On March 6, 2025, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Director, Megan Gallagher to deliver complaint findings for the above allegation. LPA was accompanied by an observer from CCLD’s policy division. The department reviewed resident records, facility records and conducted extensive interviews. LPA is unable to find and or meet the preponderance, per policy. It was reported that on October 19, 2024 R1 did not receive as needed pain medications as prescribed and requested. Physician’s orders for R1’s pain medication states as needed every 4 hours for pain. Statements alleged that at approximately 4:30 PM, On October 19, 2024, R1 requested pain medication. Med tech, S1, sought clarity of timing between R1’s medications before dispensing. Later in the evening, R1 again requested pain medication from S1. R1 alleged that medication was not dispensed at S1 left for water and did not return. UnsubstantiatedRead the full finding— CDSS inspection report, March 6, 2025 · control 59-AS-20241030160128

On March 6, 2025,, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met withDirector, MeganGallagher. LPA was accompanied by an observer from CCLD’s policy division. LPA conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. Regarding-Staff do not ensure that resident's pendant calls are answered in a timely manner. Records reviews, call records and staff interaction records did not support the allegation. Regarding- Staff did not ensure that resident's toileting needs are met. R1 records show R1 independently toilets and requires intermittent assistance. Supporting evidence was not found to support that R1's toileting needs are not met As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened orRead the full finding— CDSS inspection report, March 6, 2025 · control 59-AS-20241031111456

On February 12, 2025, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Administrator. The department conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy for the following allegations: Staff did not provide medical attention to resident in a timely manner- The two incident for R1 that were mentioned on the complaint found that there was not sufficent evidence that the allegation could be substantiated. The incidents in July and August of 2024 where R1 experienced changes in their condition were documented and staff interviewed to show that staff responded as directed by R1's physician and according to R1's plan of care. Following each incident of a previously unidentified care need, R1's physician was contacted and the plan of care was updated as needed. Facility has insufficient staff to provide care to residenRead the full finding— CDSS inspection report, February 12, 2025 · control 59-AS-20240904164258

Licensing Program Analysts (LPAs) Graham Gunby and Cheyenne Ratajczak arrived unannounced on 12/18/2024 to complete and deliver findings to a complaint received on 1/17/2024. LPAs met with Executive Director, Megan Gallagher and explained the purpose of the visit. Throughout the course of the investigation, the department conducted interviews and record reviews. Please continue to LIC9099C.. Substantiated— CDSS inspection report, December 18, 2024 · control 59-AS-20240117154538

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday September 26, 2024, to complete and deliver findings to a complaint received on 7/25/2024. LPA met with Administrator Megan and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator and staff. LPA reviewed R1’s physicians report, incident report, police report, resident assessment, monthly billing, email communication, and nursing notes. The result of the investigation is as follows: Allegation: Resident wandered away from the facility due to lack of care and supervision. At approximately 9pm on July 8, 2024, LPA learned that the delayed egress alarm on a second-floor door went off. Staff checked the alarm but did not check the hallway nor did they check to ensure all residents were accounted for. When the morning shift began on July 9, 2024, they noticed that R1 was not in the facility. Per the police report, the facility called in a missing person’Read the full finding— CDSS inspection report, September 26, 2024 · control 59-AS-20240725172932

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday September 26, 2024 to complete and deliver findings to a complaint received on 1/11/2024. LPA met with Administrator Megan and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator and staff. LPA reviewed staffing schedules, staff files, and CSMDR. The result of the investigation is as follows: Allegations: Unqualified staff is providing care and supervision to diabetic residents, Unqualified staff is administering medication, Staff mishandled the residents medical records LPA reviewed text messages between S1 and various facility employees. These text messages reveal that there were shifts when a nurse was not scheduled. However, LPA previously cited the facility on 10/11/2023 regarding unqualified staff performing insulin administration. LPA did not obtain or review any new information that the facility continued this practice after the citation waRead the full finding— CDSS inspection report, September 26, 2024 · control 59-AS-20240111104820

LPA Parks arrived on Monday March 11, 2024, 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 generator’s test run log and the facility’s Emergency and Disaster Plan. LPA learned that there was a city-wide power outage from Sunday February 11th until the evening of Monday February 12th. While the facility does have a portable generator (which they share with their next-door sister facility Summerset Lincoln Assisted Living), the generator was not functioning properly. Upon the power outage, the generator was not putting out voltage. The generator service company determined there was a fuse that had burned out on the generator. The issue was immediately fixed and the company conducted the yearly service. The facility immediately began to follow their Emergency and Disaster Plan by dRead the full finding— CDSS inspection report, March 11, 2024 · control 59-AS-20240206164023

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 SRead the full finding— CDSS inspection report, October 10, 2023 · control 59-AS-20230406113411

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. UnsubstantiatedRead the full finding— CDSS inspection report, September 28, 2023 · control 25-AS-20230117164126

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 carRead the full finding— CDSS inspection report, September 28, 2023 · control 59-AS-20230310160924

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 SubstantiatedRead the full finding— CDSS inspection report, June 15, 2023 · control 25-AS-20221122121630

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 thaRead the full finding— CDSS inspection report, June 15, 2023 · control 25-AS-20230111151017

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 evRead the full finding— CDSS inspection report, June 6, 2023 · control 25-AS-20230214091816

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 viRead the full finding— CDSS inspection report, June 1, 2023 · control 59-AS-20230315134023

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 repoRead the full finding— CDSS inspection report, May 11, 2023 · control 25-AS-20230119123543

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 physiRead the full finding— CDSS inspection report, May 11, 2023 · control 59-AS-20230406152123