Summerset 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.

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 provide adequate hygiene care to resident.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Danielle Barry and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed a resident (R1), a resident’s conservator, six staff members (S1-S6), and Barry. LPA Moleski reviewed an incident reported dated 11/17/24 which described R1 as having a change of condition. R1 was off baseline, and the left side of their face was swelling, according to the report. R1 was sent to a hospital for further evaluation. Shortly after R1 was sent to the hospital, the Community Care Licensing Division (CCLD) received a report alleging R1’s general hygiene was poor, and in particular that R1 had dead skin and other skin breakdown on their palms. [continued on 9099-C] Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 6, 2025 · control 27-AS-20241120164437

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: Facility staff are not dispensing medications as prescribed Facility staff are falsifying resident records

On 01/10/25 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to open a complaint into the above allegations. LPA identified herself upon arrival, stated the purpose of the visit, and asked to speak to the Designated Facility Administrator/Executive Director (ED) Danielle Barry. LPA met with the ED and a brief interview followed. This LPA requested a copy of the schedule for carestaff and med techs along with contact information as well as a copy of the resident roster. The LPA then toured the facility and observed 3 residents sitting in the conversation area of the lobby chatting, 2 kitchen staff cleaning the dining room while 3 residents finished their meals, an activities staff member packing up holiday decorations, and a housekeeping servstaff member servicing resident rooms. In memory care, this LPA observed 7 residents sitting in the common area watching TV and being supervised by 1 caregiver. LPA observed another caregiver assisting a rthe state’s words, verbatim · CDSS document, Jan 10, 2025 · control 27-AS-20250103102458

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 Staff did not report incident to resident's responsible party

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegations. LPA Lund met with Administrator Danielle Barry. and explained the reason for the visit. Census: 93 Resident sustained unexplained injuries while in care - LPA Lund reviewed facility records, Resident’s (R1) medical records and interviews with staff. Based on reviewed facility records, Resident’s (R1) medical records and interviews with staff. Unusual Incident/Injury Report (LIC624) dated 6/7/2024 that R1 was sent to Kaiser Roseville for evaluation and treatment on 6/3/2024. Kaiser Admission paperwork dated 6/3/2024 stated that R1 was admitted to the Emergency Room (ER). Hospital admission physical exam states note acute distress and R1’s appearance is well- developed. Report states no unexplained injuries to R1. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 6, 2024 · control 27-AS-20240613163034

Allegation investigated: Staff are not providing adequate supervision of resident to reduce injuries Staff did not seek medical attention for resident in a timely manner Staff did not address resident's skin issues in a timely matter

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA Valerio met with Administrator Danielle Barry and explained the purpose of the visit. The investigation consisted of interviews with staff, interviews with responsible parties, observation of the facility, review of medical records, review of hospice records, review of facility documentation, and review of documentation provided by the Reporting Party (RP). Staff are not providing adequate supervision of resident to reduce injuries / Staff did not seek medical attention for resident in a timely manner According to the Reporting Party (RP), Resident 1 (R1) "is prone to wander, fall, and suddenly injure [themselves] should [R1] be left unsupervised or not be properly cared for." RP also stated that R1 has fallen and injured R1's face on three separate occasions and Summerset has not done enough to ensure R1 is safe. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 12, 2024 · control 27-AS-20240515152430

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: Resident fell sustaining a fractures due to staff neglect Staff did not seek medical attention for resident Staff did not notify resident's authorized representative of incident Staff are not meeting resident's hygiene needs

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Danielle Barry and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. According to facility notes, incident reports, and medical records, a resident (R1) suffered numerous falls at this facility between 9/10/18 and 11/10/23. Falls documented during this time period include the following: On 9/10/18, R1 fell while family members were visiting. On 5/21/20, R1 fell on their right hand, and swelling and bruising were observed. R1’s physician was notified. On 6/22/23, R1 suffered an unwitnessed fall and complained of knee pain. R1 was sent to the hospital and R1’s physician was notified. [continued on 9099-C] Substantiatedthe state’s words, verbatim · CDSS document, Jul 1, 2024 · control 27-AS-20231204145833

Allegation investigated: Staff do not ensure resident rooms are kept clean. Staff do not ensure that resident has a working call button. Staff do not follow infection control practices. Resident developed a stage 3 pressure injury while in care. Staff retained resident with a prohibited health condition.

On 6/21/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator (DFA). LPA met with Danielle Barry who assumed her on position on 2/16/24. At the time census was 83 with 30 residing in memory care. LPA conducted a walkthrough of the facility. LPA observed 7 residents in the assisted living dining room having breakfast and the Resident Services Director distributing medications. In memory care, LPA observed a med tech distributing medications room-to-room. LPA also observed 7 residents finishing breakfast in the dining area and another 7 residents watching T.V. in the common area. LPA observed the DFA assisting a resident to the elevator as they were being picked up for a doctor's appointment. There were 2 care staff in the kitchenette area cleaning up, and the Dthe state’s words, verbatim · CDSS document, Jun 21, 2024 · control 27-AS-20231128084622

Allegation investigated: Staff handled resident in a rough manner.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with facility administrator Danielle Barry and explained the purpose of the visit. This investigation consisted of observation, interviews, and record review. During the course of this investigation, LPA Moleski interviewed eight staff members (S2-S9), a resident's responsible party (R1's RP), a hospice nurse (R1's RN), and a resident (R1). During an interview, R1's RP claimed to have observed a male staff member kick R1's knees out from under R1 in order to get R1 to sit on a toilet. During an interview, R1's hospice nurse said that they had not observed any such maneuvers being used at this facility, and had no suspicions of physical abuse committed by the staff. R1's hospice nurse said they had not observed any unusual or suspicious injuries on R1. [continued on 9099-C] Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 24, 2024 · control 27-AS-20240220140418

Allegation investigated: Staff do not follow infection control protocols. Staff are not addressing a scabies outbreak. Staff did not report a scabies outbreak as required.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with facility administrator Danielle Barry and explained the purpose of the visit. LPA Moleski toured the second floor and met with a resident (R2). LPA Moleski reviewed hospital discharge paperwork for R2. R2 was diagnosed with scabies on 4/9/24, according to the discharge paperwork. R2 returned to this facility on 4/10/24. LPA Moleski visited R2's room and observed two caregivers (S2 and S3) applying ointment to R2 in bed. S2 and S3 were wearing gloves, but were not wearing gowns or masks. LPA Moleski observed gloves discarded in an uncovered trash can inside R2's room. LPA Moleski observed S3 discard used gloves in an uncovered trash can in a common area. [continued on 9099-C] Substantiatedthe state’s words, verbatim · CDSS document, Apr 15, 2024 · control 27-AS-20240220140418

Allegation investigated: Resident received unlawful eviction notice

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced along with ombudsman Suhair Siraj to open this complaint investigation. LPA Moleski met with Danielle Barry and explained the purpose of the visit. LPA Moleski reviewed a copy of an eviction notice served to a resident (R1) on February 9, 2024. According to the notice, R1 was being evicted "due to inappropriate behavior that occurred in the facility." No further description of the alleged behavior was provided. The notice does not include, as required by 22 CCR Section 87224(d)(1)(B-D), specific facts to permit determination of the date, place, witnesses and circumstances concerning the reasons relied upon for the eviction, nor does it contain resources available to assist in identifying alternative housing and care options, nor does it include a statement informing residents of their right to file a complaint with the licensing agency, nor does it contain contact information for the licensing agency or for the ombudsmthe state’s words, verbatim · CDSS document, Mar 4, 2024 · control 27-AS-20240223134826

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 does not ensure resident receives assistance with wheelchair Staff does not ensure resident is brought down for meal service

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with Danielle Barry and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed a resident (R1) and five staff members (S1-S5). LPA Moleski reviewed R1’s file. R1’s assessment states that R1 is to receive two-person assistance with transfers. R1’s preplacement appraisal states that R1 needs assistance getting into R1’s wheelchair. R1 is unconserved and has no powers of attorney documented. R1 was admitted to the facility as of December 11, 2023. In an interview on January 25, 2024, R1 said that R1 was not comfortable with transferring out of bed upon admission, that R1 suffered pain when trying to get up, and that R1 suffered from nausea when out of bed for too long. [continued on 9099-C] Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 12, 2024 · control 27-AS-20240119151219

Allegation investigated: Licensee does not ensure facility has sufficient staffing to meet the care needs of residents Staff do not ensure residents receive bathing service in a timely manner

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Elisa Weathers and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed Weathers and 15 staff members (S1-S15). S1, S6, S7, S8, S10, S11, S12, and S13 work in memory care. S3, S4, S5, and S11 work in assisted living. LPA Moleski interviewed seven residents (R1-R7). R1, R2, R3, R5, R6, and R7 live in assisted living. R4 lives in memory care. In an interview, Weathers said staff hours had been reduced recently. LPA Moleski reviewed staff schedules and resident rosters for this facility. [continued on 9099-C] Substantiatedthe state’s words, verbatim · CDSS document, Feb 1, 2024 · control 27-AS-20231201144701