Vista Roseville Memory Care

Allegation investigated: - Resident sustained an injury due to staff neglect. - Staff left hazardous item accessible to residents in care.

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced 10/03/2023 to deliver final finding for a complaint Community Care Licensing (CCL) received on 02/16/2023. LPA met with Executive Director, Janelle Douglas, and explained the purpose of the visit. Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents, such as resident’s (R1) physician's report, admission agreement, unusual incident/injury report, medical records, personal service plan, care profile, progress notes, temporary service plan wound, and transmission. Continued page LIC-9099C. Substantiated Allegation: Resident sustained an injury due to staff neglect. – Substantiated. According to interviews conducted, R1 sustained an injury while in the facility on 02/05/2023. R1 sustained a burn the size of a half dollar on R1’s left leg. The Department received an unusual incident/injury report on 2/12/2023 . Incident report indicated on 02/05/2023 staff were changing R1 prior to bedtime and observed blisters on R1’s left leg from the knee to mid-thigh. Staff provided first-aid and contacted EMT to request an urgent assessment and send out to the hospital. R1’s Power of Attorney (POA) and primary care physician were contacted as well as Executive Director. R1 refused to be transported to the hospital and POA agreed. Although R1’s burn was unwitnessed, interviews with staff and witnesses determined that R1 was burned from an electric fireplace that was located on the floor in the common area of the facility. On 02/07/2023, R1 was taken to the hospital due to high blood pressure and the burn wound appeared to be at risk for infection. R1 returned to the community the same day with wound care orders and supplies. The facility was to monitor R1 for pain or any signs or symptoms of infection. The facility nurse was to reassess the wound healing progress at 7 and 14 days to ensure proper treatment is being administered. Wound dressing changes were to be performed by Med Techs on shift, all of which had been properly trained on the wound cleanse and dress process. Medical records indicated that the R1’s burns were second and first degree burns to lateral left lower leg, knee, and thigh. At the time of R1’s hospital visit on 02/07/2023, burn did not show signs of infection and R1 is stable for discharge back to memory care facility. On 2/08/2023, R1 returned to the hospital concerning burn care. The hospital provided R1 with bacitracin, gauze, and nonadherent and tape and R1 returned to the community. On 2/13/2023, R1 returned to the hospital for re-evaluation of burn wounds. R1 diagnosed with third degree burn on left leg and will require daily wound care. R1 was discharged from the hospital and admitted to skilled nursing facility on 2/15/2023. R1 was admitted into the facility on 10/12/2021. The Department requested and reviewed R1’s physician’s report that was completed on 09/15/2021. According to R1’s physician’s report, R1’s primary diagnosis is progressive supranuclear palsy (PSP) and secondary diagnosis is dementia and Parkinson's. R1 cannot manage their own treatment, medication, and equipment. R1 has visual impairment, bowel impairment, bladder impairment, and motor impairment/paralysis. R1 uses an assistive device such as a walker and cannot walk unassisted. R1 is confused/disoriented and cannot locate self temporally or spatially. R1 has wandering behavior and is not able to leave the facility unassisted. R1 is non-ambulatory based upon both physical and mental condition. Facility completed R1’s personal service plan on 10/09/2021. According to R1’s service plan, R1’s PSP condition causes balance with balance, movement, coordination. R1 shuffles when R1 walks. Facility is to provide escort services and encourage and re-direct R1 to use walker. R1 requires physical assistance related to the inability to stand independently during dressing or grooming tasks, and bathroom tasks. R1 is independent going to and from the dining room or community activities. R1 can transfer self and needs standby assist occasionally. Care staff is to monitor R1’s gait and balance. The Department determined that although R1’s injuries were not a direct result of staff neglect, facility staff did however neglect to provide a safe environment and did not ensure that the electric fireplace was inaccessible to residents with a diagnosis of Dementia. Allegation: Staff left hazardous item accessible to residents in care. – Substantiated. According to interviews conducted, staff reported that that R1 was sitting too close to an electric fireplace which was located on the ground in the common area of the facility. This facility services residents with a diagnosis of Dementia and therefore must ensure that any items that could constitute danger to residents should be inaccessible. At the time of the incident, R1 was wearing shorts. On 2/5/2023, LPA Keosavang arrived at the facility unannounced to open complaint investigation. LPA met with Executive Director, Morgan Greenwood Whinery, and explained the purpose of the visit. LPA discussed allegations with ED and toured the facility with ED. ED indicated R1 was recently sent to the hospital due to an injury. ED indicated an unusual incident report was submitted to CCLD for review. A care staff had observed R1 with blisters on R1’s left leg during a change prior to bedtime. It was determined that R1 was injured due to a portable electric fireplace located in the common area. R1 was assessed by EMT and was recommended to be transferred to the hospital, however, R1 refused. Facility notified R1’s POA. LPA Keosavang observed the electric fireplace located in the common area of the facility. LPA observed the electric fireplace to be unplugged but still accessible to residents in care. ED pointed out that the facility had disconnected the wire on the electric fireplace so it cannot be connected to an outlet. ED stated electric fireplace will not be used moving forward. The Department interviewed a total of three (3) facility staff. Interview statements received from staff indicated that R1 had a habit of sitting close to the fireplace and moving around in their wheelchair. Based on interviews and observations, the facility did not ensure residents had a safe living environment by resident’s having access to an electric heater. The Department finds the above allegations 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. The deficiencies are cited on 9099-D, per Title 22 Regulations, Division 6. The citation issued today is under review and a future civil penalty may apply based on Health and Safety code §1569.49(e) H&S. In addition, civil penalties in the amount of $500.00 are assessed today for a resident sustaining a serious bodily injury while in care. Failure to correct the deficiencies may also result in civil penalties. Appeal rights provided. Exit interview conducted and report provided. Allegation: Staff did not care for resident's wound in a sanitary manner. – Unsubstantiated. According to complainant, R1 had multiple burns. On 02/9/2023, complainant observed staff same in to R1’s room to treat the wound during the visit and laid the gauze and scissors on the dirty floor. Staff was wrapping R1’s injuries with dirty supplies. The Department interviewed a total of two (2) facility staff. S1 indicated the direction for the after care for R1’s burn is to keep the burn clean and dry. Staff is to dress R1 in shorts to ensure there was no irritation and it was easier to change the bandage for the burn. S1 indicated caregivers did not change R1’s wound and it was the responsibility of the nurse and Med Tech. On 8/10/2023, LPA Keosavang arrived at the facility to conduct complaint investigation. LPA requested to interview the nurse and Med Tech. According to Operational Specialist, Sharon Monck, nurse, and the Med Tech that provided wound after care is no longer working at the facility. The facility provided Med Tech’s contact information. On 8/25/2023, LPA called Med Tech and left a detailed message. LPA requested for Med Tech tor turn LPA’s call. LPA unable to receive interview statement from Med Tech. Allegation: Staff did not ensure resident had clean laundry. – Unsubstantiated. On 2/9/2023, complainant observed R1 not wearing shows. Socks that R1 was wearing were wet from something that R1 had been drinking spilling on R1’s feet. According to R1’s personal service plan, R1’s laundry days are Wednesday and Saturday. Staff is to assist R1 with the set-up, selection or laying out of clothes. R1 can perform the following tasks with physical assistance as needed, putting on/taking off clothing, socks, and shoes. On 8/10/2023, LPA Keosavang arrived at the facility unannounced to conduct complaint investigation. LPA interviewed a total of two (2) staff. Interview statement received from S1 indicated, caregivers in the morning shift are responsible for residents’ laundry. Caregivers are to check residents’ laundry basket every morning to see if they are full or not. Residents have their scheduled laundry days and if caregivers observed laundry baskets are full, they will make sure to do the residents laundry. S1 explained R1 did not have a lot of clothes so staff had to wash R1’s clothes more frequently compared to other residents in care. Housekeeper will also assist with laundry if needed. Interview statement received from S2 indicated, housekeeper assist with laundry, but it is the caregiver’s responsibility. S2 stated when caregivers see that residents’ laundry basket is full, they would do it right away or on their scheduled days. S2 stated if a resident in care had an incident caregiver would change out the sheets right away and throw it in the washer and dryer. Allegation: Staff did not ensure that resident was adequately fed. – Unsubstantiated. On 2/9/2023, complainant observed R1’s wheelchair was covered with food. Staff did not wipe R1’s hands after R1 ate a piece of chocolate cake with chocolate syrup. Staff don’t keep the facility clean, and the floors are covered with food. Complainant is concern with the amount of food R1’s eating in R1’s condition. R1 does not have use of both arms and struggling to eat due to Dementia. Complainant stated is concern that R1 was losing weight since R1 moved into the facility. According to R1’s personal service plan, R1 is on a regular diet. R1’s food is to be cut up in the kitchen. On 2/15/2023, LPA conducted a tour of the facility with Executive Director, Morgan Greenwood Whinery. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. On 8/10/2023, LPA Keosavang arrived at the facility unannounced to conduct complaint investigation. LPA interviewed a total of two (2) staff. Interview statement received from S1 indicated, R1 was on a regular diet. S2 stated there is plenty of food at the facility to feed all the residents in care. Allegation: Staff did not ensure resident's hygiene needs were met. – Unsubstantiated. On 2/9/2023, complainant observed R1’s wheelchair was covered with food. Staff did not wipe R1’s hands after R1 ate a piece of chocolate cake with chocolate syrup. Staff don’t keep the facility clean, and the floors are covered with food. According to R1’s personal service plan, R1 schedule showers days are Monday and Friday between 7am and 8am. On 8/10/2023, LPA Keosavang arrived at the facility unannounced to conduct complaint investigation. LPA interviewed a total of two (2) staff. Interview statement received from S1 indicated, R1 was able to feed self. S1 explained R1 would “make a big mess” when eating due to R1’s diagnosis. S1 stated when R1 would make a big mess when eating caregivers would take R1 back to R1’s room and wash/clean R1 and bring R1 back out to the common areas. Caregivers would assist R1 daily with brushing teeth, washing face, and showers on schedule days. Interview statement received from S2 indicated, R1 gets dirty when eating. S2 explained when R1 is finished eating caregiver would clean R1 right away. “They don’t leave him dirty.” S1 stated R1 is scheduled for showers two days a week and as needed if there are accidents. Allegation: Staff did not keep the facility clean and sanitary. – Unsubstantiated. On 2/15/2023, LPA Keosavang arrived at the facility unannounced and met with Executive Director, Morgan Greenwood Whinery. LPA toured the facility with ED. LPA observed common areas, courtyard, kitchen, medication room, and five (5) residents’ bedrooms and bathrooms. LPA observed the facility to be clean and sanitary. The Department has investigated the above listed allegations. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report will be provided to the facility.the state’s words, verbatim · CDSS document, Oct 3, 2023 · control 25-AS-20230210141515

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: Oct 4, 2023

87705(f)(1) Care of Personal with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on records review, observation, and interviews, electric fireplace located in common area was accessible to residents in care causing R1's injuries. This poses an immediate health, safety, and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Oct 3, 2023

Plan of correction: The facility agrees to remove electric fireplace from the common area and submit a statement of understanding and compliance to CCL via email by POC due date, 10/04/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Oct 4, 2023

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 records review, observation, and interviews, the facility did not ensure that electric fireplace was inaccessible to residents in care. This poses an immediate health, safety, and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Oct 3, 2023

Plan of correction: The facility agrees to review regulation section 87468.1 and submit a letter of understanding to CCL via email by POC due date, 10/04/2023.

Type of visit: Required - 1 Year

The narrative section of the state’s online copy of this report is blank.

Allegation investigated: Staff did not provide all of residents records to resident's authorized representative.

On 02/22/2023, Licensing Program Analyst (LPA) Keosavang arrived at the facility unannounced to commence a complaint investigation into allegation listed above. LPA met with Executive Director (ED), Morgan Whinery, and discussed the elements of the allegation. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. During the course of investigation, the Department interviewed ED and obtained pertinent documents relevant to the complainit investigation such as, authorization for release of records, affidavit custodian of records, letter of request from law group, and email communications. Continue on page LIC9099-C. Substantiated Interview statement received from ED indicated, on 01/18/2023 the facility received a letter from Clement Law Group PC requesting for copies of any and all records regarding resident (R1). On 01/23/2023, ED provided copies to management for approval. ED stated requested documents scanned over to management was approved the same day and submitted to the law group. ED provided copies of request and authorization for release of records to LPA for review. Authorization for release of records indicated this request is made pursuant of Health and Safety Code Section 1569.269(a)(21), which provides in part as follows: Residents have the right to prompt access to review all of their records and to purchase photocopies. Photocopies must be provided within two business days at a cost not to exceed the community standards for photocopies. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Health and Safety Code, Title 22, Division 6, Chapter 3.2 are being cited on the attached LIC9099D. Appeal rights provided to the facility. An exit interview was conducted with Morgan Whinery, Executive Director, and a copy of this report will be provided to the facility via email.the state’s words, verbatim · CDSS document, Feb 22, 2023 · control 25-AS-20230216085506

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(21) · Plan of correction due date: Feb 27, 2023

1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (21)To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement is not met as evidenced by: Based on records review and interviews, On 1/18/23 records were requested. On 1/23/23 R1's records were provided and exceeded two days. This poses a potential health, safety, and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2023

Plan of correction: ED agrees to review Health and Safety Code section 1569.269 and submit a letter of understanding to CCL by POC due date, 02/27/2023.

Allegation investigated: Facility did not answer communications promptly and appropriately to the resident's representatives.

Licensing Program Analyst (LPA) Keosavang arrived at the facility unannounced on 10/04/2022 to commence a complaint investigation. LPA discussed the elements of the allegation with Reigonal Nurse, Robyn Moore. LPA ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. During the course of investigation, the Department interviewed facility staff and obtained pertinent documents relevant to the complainit investigation such as, resident roster and authorization for release of records form from the facility. Continue on page LIC9099-C. Substantiated According to Brookdale Roseville's authorization for release of records form, resident's (R1) Responsible Party (RP) submitted request on 08/22/2022. On 09/16/2022, RP followed up with ED on the status of the request. Interview statement received from ED, indicated the authorization for release of records form had been misplaced and was found when RP asked for the status of the request. ED stated it took a couple days to get the records together for RP. According to ED, RP picked up R1's records on 09/21/2022 at the facility. On 10/03/2022, Complainant stated Executive Director, Chantal Salinas, did not reach out or provided requested documents. Regional Nurse notified LPA that ED, Chantal Salinas, had left the facility without notice. Regional Nurse stated ED left without notifying staff that authorization for release of records were not completed and provided to R1's RP. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Health and Safety Code, Title 22, Division 6, Chapter 3.2 are being cited on the attached LIC9099D. Appeal rights provided to the facility. An exit interview was conducted with Chantal Salinas, Executive Director, and a copy of this report will be provided to the facility via email.the state’s words, verbatim · CDSS document, Oct 4, 2022 · control 25-AS-20220928132255

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(21) · Plan of correction due date: Oct 7, 2022

1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (21)To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement is not met as evidenced by: Based on records review and interviews, R1's records were provided to RP aboout month later from the request date. This poses a potential health, safety, and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Oct 4, 2022

Plan of correction: Regional Nurse agrees to contact Records Manager and provide requested docuemnts. Regional Nurse is provide proof and submit to LPA by POC due date, 10/07/2022.

Allegation investigated: Facility did not answer communications promptly and appropriately to the resident's representatives.

Licensing Program Analyst (LPA) Keosavang arrived at the facility unannounced on 09/22/2022 to commence a complaint investigation. LPA discussed the elements of the allegation with Executive Director, Chantal Salinas. LPA ensured he 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. During the course of investigation, the Department interviewed facility staff and obtained pertinent documents relevant to the complainit investigation such as, resident roster and authorization for release of records form from the facility. Continue on page LIC9099-C. Substantiated According to Brookdale Roseville's authorization for release of records form, resident's (R1) Responsible Party (RP) submitted request on 08/22/2022. On 09/16/2022, RP followed up with ED on the status of the request. Interview statement received from ED, indicated the authorization for release of records form had been misplaced and was found when RP asked for the status of the request. ED stated it took a couple days to get the records together for RP. According to ED, RP picked up R1's records on 09/21/2022 at the facility. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Health and Safety Code, Title 22, Division 6, Chapter 3.2 are being cited on the attached LIC9099D. Appeal rights provided to the facility. An exit interview was conducted with Chantal Salinas, Executive Director, and a copy of this report will be provided to the facility via email.the state’s words, verbatim · CDSS document, Sep 22, 2022 · control 25-AS-20220920164544

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(21) · Plan of correction due date: Sep 29, 2022

1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (21)To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement is not met as evidenced by: Based on records review and interviews, R1's records were provided to RP aboout month later from the request date. This poses a potential health, safety, and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Sep 22, 2022

Plan of correction: Executive Director provided resident's records to RP.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Case Management- Incident visit. LPA met with Resident Care Coordinator (RCC), Juan Ramirez, and explained the purpose of the visit. Prior to entering the facility, the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility. Regional Nurse, Robyn Moore, arrived at a later time. The purpose of the visit was to follow-up on an unusual incident/injury report that was sent to Community Care Licensing (CCL) on 05/11/2022. The report indicates that a memory care resident (R1) made an allegation of physical abuse by husband. The report also indicates that on 05/05/2022 R1 made an statement to facility staff of a sexual assault occurred. LPA interviewed Regional Nurse regarding the report. The interview with Regional Nurse indicates that R1 had moved in the facility for a couple months. The facility notified R1's POA, Primary Care Physician, Ombudsman and Police Department. Skin check was performed. No bruises or new skin alterations noted. The facility are conducting an internal investigation and care plan will be updated to include that no male staff to personally care for R1. The facility plans to retrain staff regarding mandated reporting started on 05/11/2022 to be completed by 5/13/2022. LPA requested for R1's physician report, service plan, updated care plan, and copies of training LPA toured the facility together with Regional Nurse to ensure health and safety of residents in care. In the areas toured no immediate health, safety, or personal rights violations were observed At this time, deficiencies are not being cited. Exit interview conducted and a copy of the report left at the facility.the state’s words, verbatim · CDSS document, May 12, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 4/7/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Resident Care Coordinator (RCC), Juan Ramirez, 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 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 toured the interior and exterior of the facility together with Resident Care Coordinator to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, one (1) bathroom, kitchen, medication room, and laundry room. In the areas toured no immediate health, safety, or personal rights violations were observed. Regional Nurse, Robyn Moore, arrived at a later time. LPA, Regional Nurse, and Resident Care Coordinator, 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, Apr 7, 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.

Allegation investigated: Facility did not safeguard resident's personal property and did not reimburse resident for lost property.

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 11/16/2021 to conduct complaint investigation. LPA met with Executive Director, Sherrie Kuar, and explained the purpose of the visit. Prior to initiating 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 and contacted licensee and completed a facility risk assessment. 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. Throughout the course of complaint investigation, the Department conducted interviews and obtained documents such as LIC 621 client/resident personal property and valuables and copies of check inquiry summary. ***************************************** Continue on page LIC 809-C ************************************************* Substantiated It was discovered that R1’s hearing aid, fitted sheets, and clothing were missing. The facility was unable to locate the missing items. It was discovered that the facility offered to replace the missing items. According to Executive Director, Business Office Coordinator (BOC) had contacted Corporate to see if a check was delivered to Complainant. At the time of opening the complaint there had been no reimbursement for the items. Since the complaint has been opened, facility has provided reimbursement for $54.80 on 10/14/2021. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC9099D. Appeal rights provided to the facility. An exit interview was conducted with Sherrie Kuar, Executive Director, and a copy of this report will be provided to the facility via email. According to Complainant, concerns about record keeping regarding R1’s stool consistency and constant phone calls because of what Complainant believe to be incomplete record keeping or dishonesty by Med-tech (MT). Complainant stated facility staff (S1) is telling Complainant something believable and Executive Director tells Complainant something completely different as she instructed staff to do. R1’s Progress Notes revealed that R1 had no bowel movement (BM) on 5/18/2021, 5/19/2021, and 5/20/2021. On 5/21/2021, S1 called R1’s POA and left a voicemail stating R1 has not had a BM for three days. MT 1 called and notified hospice. Hospice stated since R1 does not have any discomfort or pain, the facility will wait until R1’s POA calls back and decides what actions to take. On 5/22/2021, R1’s POA spoke to MT 1 and was notified of R1’s BM and contacted hospice again. According to Executive Director, R1’s medication was causing R1’s no BM. Once R1’s POA and hospice was notified, the facility requested to discontinue the medication. On 5/22/2021 in the evening, R1 was reported to have XL BM. This agency has investigated the above listed allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED. An exit interview was conducted with Sherrie Kuar, Executive Director, and a copy of this report will be provided to the facility via email.the state’s words, verbatim · CDSS document, Nov 16, 2021 · control 25-AS-20210903112301

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Nov 19, 2021

87217 Safeguards for Resident Cash, Personal Property, and Valuables. (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources.This requirement is not met as evidenced by: Based on records review and interviews, R1’s hearing aid, fitted sheets, and clothing were missing. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 16, 2021

Plan of correction: Administrator agrees to review Title 22, Division 6, Chapter 8 Article 04. Operating Requirements 87217 Safeguards for Resident Cash, Personal Property, and Valuables. Administrator agrees to submit written documentation to CCL that regulation was reviewed.

The state marks this report as 8 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.