Summerset Lincoln Assisted Living

Allegation investigated: Staff mismanaged resident’s medication

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday September 28, 2023, to complete and deliver findings to a complaint received on 9/15/2023. LPA met with Administrator Jeff and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator and Wellness Director. LPA interviewed R1 and R2 regarding the allegations. LPA reviewed R1’s file at the facility including physicians report, progress notes, and MARs. The result of the investigation is as follows: On 8/13/2023, R1 was running low on two medications (Atrovastatin and Amloidipine). Staff reordered the medication, however, not within the timeframe for resident to not miss any doses. Additionally, one medication needed the primary physician’s signature for the prescription to be renewed. Based on interviews, R1 was out of one medication as of 8/15 or 8/16 (unsure due to inconsistent documentation on MARs). Based on R1’s MARs, one medication was out for 3 days and the other for 5 days. Substantiated Based on the information detailed above, LPA finds the allegation 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. occurrence as it is for temporary amount of time. Based on the evidence provided, 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, Sep 28, 2023 · control 59-AS-20230911134523

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Sep 29, 2023

87465(a)(5) 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, Sep 28, 2023

Plan of correction: Administrator to submit plan of med tech training regarding medications.

Allegation investigated: Resident was charged for services not rendered

LPA Parks arrived on August 31, 2023, to conclude a complaint investigation regarding the above allegation. LPA met with Administrator Jeff and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator and staff. LPA reviewed R1’s file including hospital discharge paperwork, MARs, billing records and resident notes. Based on MARs and hospital discharge paperwork, LPA determined that R1 was out of the facility for the following date: 2/11/23 – 2/13/23, 4/13/23-4/21/23, 3/21/23 – 3/28/2023. Per the signed admission agreement, the facility stops charging for care fees once the resident is out for over 7 days. Based on the admission agreement, R1 is due a care credit for three days (one day for the absence in March and two days for the absence in April). Based on R1’s transaction history, the facility only applied a credit for room service trays, but not for care fees. Substantiated Based on the information detailed above, LPA finds that the allegation is 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 interviewed residents. All residents interviewed stated that the food is served warm/hot in the dining room. Per staff interviewed, R1 sat at a table in the dining room which is directly below an AC vent. Staff interviewed stated that resident’s have not complained to them about food being served cold in the dining room. LPA reviewed call logs records for residents. Staff interviewed stated that they strive to answer call buttons within 10-15 minutes. Staff acknowledged that at times, during mealtimes when many residents press their pendants at the same time, it can take longer to answer the call buttons. Residents interviewed stated that staff answer the pendants timely. 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, Aug 31, 2023 · control 59-AS-20230515154653

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Sep 15, 2023

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: based on document review and interview, the licensee did not company with the section cited above by not crediting R1’s account for 3 care days per the admission agreement, which poses a potential health, safety or personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, Aug 31, 2023

Plan of correction: Administrator agrees to provide LPA with a copy of check for credited care days.

Allegation investigated: Staff do not respond to residents call buttons in timely manner Facility staff are not properly supervising residents who may be a fall risk Staff do not assist residents with transfers in a timely manner facility left resident on floor for extended amount of time

LPA Parks arrived on August 1, 2023, to conclude a complaint investigation regarding the above allegations. LPA met with Administrator Jeff and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the previous Administrator, current Administrator, facility staff, and current residents. LPA reviewed R1’s file including R1’s physicians report, care plan, and resident notes. LPA learned that R1 has a history of agitation and restlessness. A review of their charting notes detail how R1 would often attempt to get out of bed. Staff would often find them 'half in, half out' of bed. R1 had a PRN which would be given to help alleviate their restlessness. Charting notes also detailed staff providing frequent checks, communication with other shifts, and hospice. No interviews acknowledged that R1 was on the floor for an extended period of time. R1’s care plan stated that staff are to provide status checks four times per shift. R1’s apartment was close to the nursing station, so staff would often check outside of the established status checks. Unsubstantiated LPA was able to interview three residents who require two staff in order to help with transfers and activities of daily living. Residents interviewed stated that staff are timely in answering pendants. Staff interviewed stated that when a resident requires two staff assist, one staff will answer the pendant and call for another staff to assist. Sometimes this requires a wait period until a second staff is available. 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, Aug 1, 2023 · control 25-AS-20230120115007

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. Areas toured include but are not limited to dining room, kitchen, hallways,and activity rooms. 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: Staff are not wearing masks

Licensing Program Analyst (LPA) Jacob Williams arrived at the facility unannounced on 07/22/2022 to conduct a complaint investigation for the above allegation. LPA met with Denise Carrillo, who is filling in as Business Office Director as the Executive Director and Business Office Director are both out, and explained the purpose of the visit. Prior to the visit , LPA completed required COVID-19 testing protocols and the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA wore the following Personal Protective Equipment (PPE) during today's visit: surgical mask. During today’s visit, LPA spoke with staff (S1, S2, and S3), toured the facility and reviewed documents. LPA observed five (5) staff not wearing masks, and only (1) staff wearing their mask. As a result of this investigation, the Department finds the allegation to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies are cited on 9099-D, per Title 22 Regulations, Division 6. Exit interview conducted. A copy of this report and appeal rights were printed and provided to Denise Carrillo. Substantiatedthe state’s words, verbatim · CDSS document, Jul 22, 2022 · control 25-AS-20211229104720

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80072(a)(2) · Plan of correction due date: Aug 5, 2022

Personal Rights. (a) Each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by: Based on interviews and observation, LPA observed 5 staff not wearing masks in the facility on 7/22/2022 which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 22, 2022

Plan of correction: Executive Director or Staff In-Charge to review recent PINs and submit a statement of understanding that masks shall be worn by staff in the care home by the POC due date of 08/05/22.

Allegation investigated: Resident’s room has an odor. Resident unable to sleep due to disturbing noise. Facility dining room has flies. Facility door is locked from resident to enter. Resident’s waiting for a period of time for door to be unlocked.

Licensing Program Analyst (LPA) Jacob Williams arrived at the facility unannounced on 07/22/2022 to open the complaint investigation for above allegations. LPA met with Denise Carrillo, who is filling in as Business Office Director as the Executive Director and Business Office Director are both out, and explained the purpose of the visit. Prior to the visit , LPA completed required COVID-19 testing protocols and the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA wore the following Personal Protective Equipment (PPE) during today's visit: surgical mask. During today’s visit, LPA spoke with resident (R1), staff (S1, S2, and S3), toured the facility including areas of particular interest, and reviewed documents. The results of the investigation are as follows: Unsubstantiated Allegation: Resident’s room has an odor. There is no odor present in R1's room. R1 states it was temporary because her trash had not been taken out. When LPA arrived, the trash was empty and there was no identifiable odor. Allegation: Resident unable to sleep due to disturbing noise. LPA toured the area of the third floor and was unable to hear any noises, or "beeping". R1 states the sound is now gone is no longer disturbing her sleep. Allegation: Facility dining room has flies. LPA toured the dining room and was not able to identify any flies. There are blue lights fixed on the walls of the dining area to attract and kill bugs in the area. The dining room appeared to be very clean and in good condition. Allegation: Facility door is locked from resident to enter. The front entrance door is unlocked during normal business hours while there is a front desk staff to screen visitors. Front desk staff goes home around 6:30pm. After this time, the doors have an automatic lock when attempting to enter the facility from the outside. There are two ways to enter the facility during this time:1) call the number posted on the entrance door which goes directly to the Med Tech and ask for entry; or 2) ring the doorbell beside the door which sends an alert to the MedTech and the caregivers. Once alerted, staff will walk to front door and allow the resident inside. Residents do not often leave out of the front entrance unless they are gone with family as the courtyard is the common area for residents to get fresh air. Allegation: Resident’s waiting for a period of time for door to be unlocked. See previous paragraph for explanation of front entry door after normal business hours. It will sometimes take a short amount of time for staff to reach the front door to respond to the doorbell after-hours. 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. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 22, 2022 · control 25-AS-20220715113557

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 3/23/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Executive Director, Sabrina Boyle, and explained the purpose of the visit. Prior to initiating the annual 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 and LPA completed a facility risk assessment at the facility. LPA ensured the following Personal Protective Equipment (PPE) was worn: Surgical Mask. LPA toured the interior and exterior of the facility together with Director of Systems Operations, Andy Dahlar, to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) resident bedrooms, two (2) bathrooms, and kitchen. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Executive Director completed the infection control domain 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 and copy of report left at the facility.the state’s words, verbatim · CDSS document, Mar 23, 2022

The state marks this report as 2 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

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 and Marketing Director Tony Michael 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 dining room. 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 Resident Services Director Shalon Morris 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, Sep 8, 2021

Allegation investigated: Insufficient staffing to care for residents Unqualified staff dispensing medication to residents Medications not being reordered on time

Licensing Program Analyst (LPA) Melana Llopis arrived at the facility on 07/19/2021 to deliver complaint findings for a complaint received on 02/16/2021. LPA met with Adminstrator, Sabrina Boyle and explained the purpose of the visit. Prior to the visit LPA completed the required daily self-screening questionnaire for symptoms of Covid-19 infection to affirm no COVID-19 related symptoms; contacted facility and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and wore the following Personal Protective Equipment (PPE): N-95 masks. Additionally, LPA was screened by staff, Trish Pugh upon entering the facility. Throughout the course of the investigaiton, LPA conducted multiple interviews and reviewed documentation pertinent to the investigation. Results are as follows: ***Continuation on LIC-9099C*** Unfounded Allegation: Insufficient staffing to care for residents Complaint alleged the facility did not have adequate staffing for R1. LPA reviewed R1’s records on 07/09/2021 and found R1 was placed on status checks every 30 minutes on 02/04/2021. R1 was placed on status checks due to an incident reported on 02/04/2021 where R1 was found after cutting herself using a tweezer. R1’s medical assessment (dated 12/06/2020) indicates R1 has known suicidal behavior. LPA spoke with Administrator who stated R1 had suicidal attempts involving medication prior to being admitted. The facility put R1 on medication management meaning R1 was unable to access medications. After the event on 02/04/2021, R1 was put on status checks and all sharp objects were removed from R1’s room. Administrator stated, since 02/04/2021, there have not been additional suicidal behavior. Incident report for R1 shows R1 was sent to the hospital the day of incident and seen by a behavioral nurse; R1 agreed to tell the facility or call 911 if they feel like harming themself. Administrator also stated R1’s husband resides at the facility but was dying at the time and that may have increased R1’s depression. LPA reviewed R1’s ADL charts for February 2021. ADL chart reviewed indicates the staff checked on R1 throughout the day and met resident’s daily needs and services. Additionally, LPA spoke with three (3) of three (3) residents in care; this included R1. Residents stated the facility staff check on them regularly and if they need any assistance they can press their pendant and the facility staff are there to help them. LPA finds allegation to be UNFOUNDED. Allegation(s): Unqualified staff dispensing medication to residents, medications not being reordered on time. Complaint alleged S1 is dispensing medication to residents and is not qualified to do so, medications are not being reordered on time for residents in care. LPA reviewed S1’s training and found S1 has been trained and certified to dispense medication to residents in care and training to be current. LPA interviewed three (3) of three (3) staff. Staff stated they received sufficient training for their positions. Caregiver staff interviewed stated they do not dispense or handle medications. LPA interviewed three (3) of thee (3) residents in care who stated the facility provides them their medications and they have not had any trouble with receiving their medications. LPA finds the allegation(s) to be UNFOUNDED. Based on the information above, LPA finds the allegation to be UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies are being cite. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 19, 2021 · control 27-AS-20210216155122