Cottages At Riverside

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.

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 did not follow resident's hospice care plan

Licensing Program Analyst (LPA) Javier Prieto visited the facility to investigate a complaint. LPA Prieto met with Executive Director Tawfik and discussed the details of the complaint. Allegation #1 - Interview with Memory Care Director (S1) states that facility medical tech staff were following the care plan for dispensing pain medication to resident #1 (R1). Medication orders were obtained during today's investigation which indicates that R1 is to receive pain medication as needed at the duration of every four (4) hours, as needed. The order reads that the form of dispensing this medication are a crushed pill, in 1 ml of liquid, and dispensed in a syringe for oral dispensing. The facility as a crush order from the hospice agency for dispensing in this manner. S1 states that med tech staff were following procedures by dispensing of pain medication per written order and are not allowed to dispense this medication with a verbal order. S1 states that med tech staff were following protocothe state’s words, verbatim · CDSS document, Apr 29, 2025 · control 56-AS-20250428092422

Allegation investigated: Staffs are not assisting resident with self administered medications. Staffs not reporting incidents to resident representative Medications given to a resident without primary physician authorization.

Licensing Program Analyst (LPA) Javier Prieto visited the facility to investigate a complaint. LPA Prieto met with Executive Director Tawfik and discussed the details of the complaint. Allegation #1 LPA Prieto addressed the matter of medications being dispensed to Resident #1 (R1) with the Memory Care Director (S1). S1 confirmed that R1’s medication was dispensed as prescribed. During the investigation, S1 provided LPA Prieto with a copy of R1’s Medication Administration Record (MAR) log, which showed that medications were given as prescribed. Allegation #2 Interviews with S1 and Executive Director (S2) revealed that communication was conducted with R1's responsible parties. Proof of this communication was obtained during the investigation. Additionally, S1 provided LPA Prieto with resident Narrative Charting regarding R1’s medication, care, and notifications to the responsible parties. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 13, 2025 · control 56-AS-20250307103003

Allegation investigated: Facility did not administer medication as prescribed. Facility did not prevent resident from becoming malnourished while in care Facility did not meet resident’s hygiene needs. Facility did not prevent resident from developing a pressure injury while in care. Resident's health declined while in the care of the facility

*****This is an amendment ******* On 4/4/2025 at 1:00 PM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to deliver the findings of the above allegations. LPA Serrano explained the purpose of the visit to the Executive Director Eva Tawfik. The investigation consisted of file review, interviews with staffs and residents as well as observation. The investigation was conducted by LPA Serrano. The allegations indicate: #1 Facility did not administer medication as prescribed. – Based on record review, the electronic medication administration record (EMAR) showed the medication was given as prescribed by the physician. *** Continuation in LIC9099C *** Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 28, 2025 · control 56-AS-20230607172908

Allegation investigated: Staff failed to asssist resident with getting out of bed Staff failed to meet resident's nutritional needs Staff failed to meet resident's hygiene needs Staff member made resident feel uncomfortable

***** This is an Amendment***** On 4/4/2025 at 1:00 PM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to deliver the findings of the above allegation. LPA Serrano explained the purpose of the visit to Excutive Director Eva Tawfik. The investigation consisted of file review, interviews with staffs and residents as well as observation. The investigation was conducted by LPA Serrano. The allegations indicate: #1 Staff failed to assist resident with getting out of bed– Based on record review of the facility Daily Assignment record, it was recorded that the resident’s needs and services plan was followed by the facility. *** Continuation in LIC9099C *** Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 28, 2025 · control 56-AS-20231031151000

Allegation investigated: Staff did not follow resident's care plan resulting in resident sustaining a pressure injury Staff handled resident in a rough manner Staff are not properly mitigating the scabies outbreak at the facility Facility's laundry machine is in disrepair Staff did not inform resident's authorized representative of resident's incident

****This is an amendment **** On 4/2/2025 at 1:00 PM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to deliver the findings of the above allegation. LPA Serrano explained the purpose of the visit to the Executive Director Eva Tawfik. The investigation consisted of file review, interviews with staffs and residents as well as observation. The investigation was conducted by LPA Serrano. The allegations indicate: #1 Staff did not follow resident's care plan resulting in resident sustaining a pressure injury – Based on staff interview, and record review, LPA is unable to identify resident #8 (R8) as residing at facility prior to or around the time of complaint initiated. As a result, there is no evidence at this time which can corroborate the occurrence of staff neglect of R8. *** Continuation in LIC9099C *** Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 19, 2025 · control 56-AS-20221107142123

Allegation investigated: Staffs do not seek timely medical care.

On 01/30/2025 at 10:15 AM, Licensing Program Analyst (LPA), Melody Brown, visited the facility to deliver the investigative findings for the above allegation. LPA Brown identified herself and discussed the purpose of the visit with Executive Director (ED) Eva Tawfik. The investigation of the allegation was conducted by Department staff. The investigation consisted of file review and interviews with relevant parties. The allegation indicates staff do not seek timely medical care. During the Department staff investigation, it was indicated that Resident #1 (R1) had a witnessed fall on 05/07/2021 at approximately 09:00 PM and it was reported that R1 used R1's right hand for balance and R1 complained of hand and wrist pain. In addition, Department staff investigation revealed that the facility contacted R1's Healthcare provider the same day. Moreover, records review indicated that R1's Healthcare provider completed a visit at the facility with R1 on 05/11/2021 and the results were receivedthe state’s words, verbatim · CDSS document, Jan 30, 2025 · control 18-AS-20210524094053

Allegation investigated: Resident died due to staff neglect. Resident developed multiple pressure injuries due to neglect. Facility failed to seek timely medical care for resident. Facility did not meet resident's needs. Facility staff did not follow sanitary precautions during care of resident.

On 01/29/2025 at 01:30 PM, Licensing Program Analyst (LPA), Melody Brown, visited the facility to deliver the investigative findings for the above allegations. LPA Brown identified herself and discussed the purpose of the visit with Executive Director (ED) Eva Tawfik. The investigation of the first allegation was conducted by Department staff. The investigation consisted of file review and interviews with relevant parties. The first allegation indicates resident died due to staff neglect. The Department staff interviewed six (6) of six (6) staffs and six (6) of six (6) staffs indicated that when Resident #1 (R1) was placed in Pacifica Senior Living of Riverside on 05/21/2021, R1 had a documented multiple health diseases and non-ambulatory. Interviews with six (6) of six (6) staffs revealed that R1 was receiving home health with nurse visits three (3) times per week. Staff #3 (S3) and Staff #5 (S5) reported to Department staff that Staff #6 (S6) contacted home health on 07/08/2021 as R1the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 18-AS-20210803122229

Allegation investigated: Resident sustained unexplained injuries in care Facility staff handled resident in a rough manner Facility spoke inappropriately to resident Facility staff did not follow hospice care plan

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director Tawfik and explained the elements if the complaint. Allegation #1, LPA interviews with staff #1 (S1) and staff #2 that reveals resident #1 (R1) sustained an injury due a fall. The fall was documented and R1's responsible party was notified as well as R1's Hospice representative. LPA interviewed R1, who stated that the injury was caused by herself when R1 attempted to stand from a seated position. R1 indicated what the injuries were and that the injuries were treated. The fall was witness by resident #2 (R2), who concurred R1's description of the fall. Allegation #2, the allegation of "facility staff handled resident in a rough manner", stems from the transfer of R1 from her wheelchair to the bed by staff. LPA interviewed S1 who indicated R1 was tranferred properly to the bed. Confirmation of the proper transfethe state’s words, verbatim · CDSS document, Jan 22, 2025 · control 56-AS-20250117145104

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: Resident sustained unexplained injuries while in care. Resident sustained multiple falls due to lack of care or supervision from staff.

**This is an amended copy. Original 9099 signed and dated on 12/13/2024** On 12/13/2024 at 1:25 PM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to deliver the findings of the above allegation. LPA Serrano explained the purpose of the visit to a staff. Staff informed the Executive Director (ED) Eva Tawfik of the visit. ED met with LPA Serrano and LPA explained the purpose of the visit to ED Tawfik. The investigation consisted of file review, interviews with staffs and residents as well as observation. The investigation was conducted by LPA Serrano. The investigation consisted of records review and interviews with relevant parties. The allegations indicate: #1 Resident sustained unexplained injuries while in care – Based on residents and staff interview, 6 out of 6 residents and 5 out of 6 staff stated that they did not witness or observe any resident that sustained unexplained injuries while in care at the facility. *** Continuation in LIC9099the state’s words, verbatim · CDSS document, Dec 13, 2024 · control 56-AS-20241119202411

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 dental needs are met. Staff do not ensure that resident is administered their medications as prescribed. Staff do not ensure that the facility is clean.

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Sales Director Julie Schevette and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews, document reviews, and facility tour. For the allegation, Staff do not ensure that resident's dental needs are met. LPA conducted 7 staff interviews. 7 out of the 7 staff stated dental services are being provided to their residents. 5 out of the 7 staff informed LPA that occasionally residents will refuse to brush their teeth due to behaviors. During the residents’ interviews, LPA Rico did not find evidence to corroborate the allegation. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 26, 2024 · control 56-AS-20240126151948

Allegation investigated: Staff do not ensure that residents' toothbrushes are stored in a sanitary manner.

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Sales Director Julie Schevette and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews, document reviews, and facility tour. For the allegation, Staff do not ensure that residents' toothbrushes are stored in a sanitary manner. LPA Rico conducted 7 staff interviews. 7 out of the 7 staff informed LPA that residents toothbrushes were not stored in a sanitary manner. 7 out of the 7 staff indictaed all resident’s toothbrushes were stored in a mix bin without a lid and had no name label.1 out of 7 staff stated they indeed provided R1 with a toothbrush that was not stored in sanitary manner to their appointment on 1/24/2024. Substantiatedthe state’s words, verbatim · CDSS document, Jun 26, 2024 · control 56-AS-20240126151948

Allegation investigated: Staff did not prevent resident from harming another resident in care Staff did not provide adequate supervision to resident in care resulting in a fall

Licensing Program Analyst (LPA) Javier Prieto arrived at the facility to initiate a complaint investigation regarding the mentioned allegations. LPA Prieto met with Executive Director Eva Tawfik to discuss the complaint elements. The investigation included interviews with staff and residents, observations, and a review of relevant documents.Regarding the allegation that staff did not prevent a resident from harming another resident in care, LPA Prieto interviewed residents R1 and R2, who were involved in the incident. Both residents stated that they do not recall any incident or altercation occurring and did not express any concerns about a lack of staff or care.LPA Prieto also interviewed staff member S1, who was present during the altercation. S1 observed the incident but was unable to prevent it as it occurred quickly. S1 took the appropriate steps by calling other staff members and ensuring that R1 received medical attention by sending them to a medical facility. ***continued on LIthe state’s words, verbatim · CDSS document, May 1, 2024 · control 56-AS-20240430155237

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 failed to provide resident food. Resident suffered from dehydration while in care. Facility failed to observe resident's change in condition. Staff failed to meet the resident's needs.

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to deliver findings for the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Executive Director Eva Tawfik. The investigation consisted of resident interviews, staff interviews, and document review. For allegation, Staff failed to provide resident food: Interviews with residents and the staff revealed that the residents are provided with food. The staff denied not providing the residents food. The residents stated that they are provided food throughout the day. The residents are provided three (3) full meals a day and three (3) snacks throughout the day. If a resident is still hungry after their meals and snacks, the residents can request additional food at any point during the day or night. A document review of the facilities menu revealed that the residents are served three (3) meals a day that includes protein, vegetables, fruit, and carbohydrates, as well as snacksthe state’s words, verbatim · CDSS document, Nov 2, 2023 · control 18-AS-20200813151731

Allegation investigated: Due to staff negligence, resident has an unexplained bruise Staff is not allowing resident to have visitors

Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to investigate the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Executive Director Eva Tawfik. The investigation consisted of a facility tour, resident interviews, staff interviews, and document review. For allegation, Due to staff negligence, resident has an unexplained bruise : Interviews with staff and documentation revealed that resident #1 (R1) did have a fall and was witnessed by staff. The fall was documented and the responsible party notified. R1 did sustained a bruise, which is explained in detail in the incident report obtained during today's investigation. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 26, 2023 · control 56-AS-20231024105428

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.