Summerset Lincoln Assisted Living

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are mishandling resident medications Resident are not treated with dignity and respect

Licensing Program Analyst (LPA) Graham Gunby arrived unannounced on 07/29/2025 to complete and deliver findings to a complaint received on 01/27/2024. LPA met with Executive Director, Sabrina Boyle and explained the purpose of the visit. Throughout the course of the investigation, the department conducted interviews and record reviews. Please continue to LIC9099C.. Unfoundedthe state’s words, verbatim · CDSS document, Jul 29, 2025 · control 59-AS-20250127111610

Allegation investigated: Insufficient staffing led to severe falls Call buttons are not answered timely

On 1/28/25, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Megan Gallagher. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 28, 2025 · control 59-AS-20241004154635

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff do not ensure that resident's medication is administered as prescribed Staff are falsifying resident’s medication administration record

On 10/31/2024 , Licensing Program Analysts (LPA) Graham Gunby and Cheyenne Ratajczak arrived and met with Administrator to deliver investigation findings. Based upon interview with the administrator and review of client roster, The department has determined the client does not reside in this facility and the complaint was made against the wrong facility. Therefore, the complaint is unfounded. The allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of the report was given. Unfoundedthe state’s words, verbatim · CDSS document, Oct 31, 2024 · control 59-AS-20241021142405

Allegation investigated: Staff mismanaged resident’s medication

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Monday July 29, 2024 to complete and deliver findings to a complaint received on 7/19/2024. LPA met with Administrator Rouzbeh and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator and staff. LPA reviewed R1’s medication list, incident report, and hourly wellness checks. The result of the investigation is as follows: LPA learned that the facility has two med techs to pass out AM shift medications. One med tech is assigned to the first floor while the other is assigned to the second floor. The third floor is divided between the two med techs. S1 provided S2 with a list of their assigned residents on the third floor. On July 19, 2024, S1 gave R1 their morning medications. Approximately 90 minutes later, S2 gave R1 a second dose of the same seven morning medications. Once the facility realized the medication error, the following people were contacted: poisonthe state’s words, verbatim · CDSS document, Jul 29, 2024 · control 59-AS-20240719114058

Allegation investigated: Facility staff did not dispense medications as prescribed Facility staff did not assist resident with dressing

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday June 27, 2024, to complete and deliver findings for a complaint received on 5/8/2024. LPA met with Administrator Rouzbeh and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed facility staff including the Administrator, Resident Services Director, Wellness Director, med techs, and caregivers. LPA reviewed R1’s file including PRN authorization, controlled drug records, communication with primary physician, resident assessment, physician reports, resident notes, physician orders, and PRN MAR. LPA interviewed staff who revealed that R1 is able to communicate when they are in pain. R1 had PRN orders for Tramadol 50mg for moderate oto severe pain and acetaminophen 325 mg as needed for pain. No staff interviews revealed that R1 was ever refused pain medication. LPA did review a faxed message to R1’s primary physician, requesting a refill order for Tramadol. R1 has a primthe state’s words, verbatim · CDSS document, Jun 27, 2024 · control 59-AS-20240508150927

Allegation investigated: Staff did not follow their emergency disaster plan

LPA Parks arrived on Monday March 11, 2024, to conclude a complaint investigation regarding the above allegation. LPA met with Administrator Rouzbeh and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, facility staff and R1. LPA reviewed the generator’s test runs 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 and Memory Care), the generator was not functioning properly. Upon the power outage, the generator was not putting out voltage. The facility rented a portable generator to use. The generator service company determined there was a fuse that was burned out on the generator. The issue was immediately fixed and the company the yearly maintenance service. The facilthe state’s words, verbatim · CDSS document, Mar 11, 2024 · control 59-AS-20240212120457

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

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 dathe state’s words, verbatim · CDSS document, Sep 28, 2023 · control 59-AS-20230911134523

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. Substantiatedthe state’s words, verbatim · CDSS document, Aug 31, 2023 · control 59-AS-20230515154653