The Village at Sydney Creek

Type of visit: Case Management - Annual Continuation

On 7/26/23 at 11:39 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced continuation visit to finalize the Annual/Required inspection started on 7/14/23. LPA met with Kirk Klotthor, Administrator, and explained the purpose of the visit. Medications are centrally stored in a locked medication room. Medications are properly labeled and checked for expiration dates. A sampling of residents’ medications show they are centrally stored prescription and PRN medication which have been logged in the medications record with proper documentation from the residents’ doctors. Proper medication dispensing instructions are followed and checked for contamination. First Aid has all proper items and is current. In 2 out of 2 residents’ medications/bubble packs, medications (2) were set aside in advance for two days. Medications can only be stored in a separate dispenser within 24 hours of dispensing to resident. Technical violation issued. Administrator will conduct a training with all med-techs and send CCL the training sign-in sheet by 8/2/23. Staff files: All required training has been completed. On the Annual Inspection Report dated 7/14/23, the facility was cited for Staff #1 (S1) not being associated with the facility, however, the Deficiency Report (LIC 809-D) and Civil Penalty did not print. LPA is providing the LIC 809-D and civil penalty to the administrator at this time with a correction: The Annual Inspection Report (LIC 809) dated 7/14/23 states “S1 was not associated with the facility during their entire time working in the facility.” The correction is that S1 was employed in August 2021 and employment ended in July 2023. Licensing records indicate S1 was associated from August 2021 through June 2022, and not associated from June 2022 through July 2023. Exit interview conducted, deficiency and civil penalty issued, and report and appeal rights given.the state’s words, verbatim · CDSS document, Jul 26, 2023

Allegation investigated: Facility exposes residents to hazardous facility grounds conditions

On 7/14/23 at 10:43 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced 10-day complaint visit to the facility listed above. LPA met with Kirk Klotthor, Administrator, and explained the purpose of the visit. On the allegation, “Facility exposes residents to hazardous facility grounds conditions,” the complainant was concerned that the areas along the sidewalks in the garden accessible to residents have holes with wires and water in them and has the potential for residents to stumble and get injured. To investigate, LPA toured the facility and interviewed the administrator. Continued on 9099-C. Unsubstantiated On 7/14/23 at 10: 50 am, LPA interviewed the administrator. The administrator states there was a plumbing leak in the garden and that a board was placed over a hole approximately 4 days ago. On 7/14/23, LPA toured the garden and observed a board in the flower bed covering the irrigation pipes. LPA walked on the board, sized approximately 2 feet x 2 feet, and walked on the soil to the right of it, approximately 4 feet long, and both were secure. There was no indication of the possibility of the board or surrounding area may collapse. Based on the evidence obtained, the allegation, “Facility exposes residents to hazardous facility grounds conditions,” is deemed Unsubstantiated at this time. Exit interview conducted, report given.the state’s words, verbatim · CDSS document, Jul 14, 2023 · control 29-AS-20230710114951

Type of visit: Required - 1 Year

On 7/14/23 at 10:43 am, Licensing Program Analyst (LPA) Chavez made an unannounced Annual/Required visit to the facility above. LPA met with Kirk Klotthor, Administrator, and explained the purpose of the visit. A tour of the physical plant was assessed, and the following was noted: LPA observed the license posted, Complaint Poster, Bill of Rights and Right to Residential Council, non-discrimination statement, and resident rights. The facility conducted Emergency Disaster Drills on 3/21/23, 8/2/22, and 8/8/22, however, drills were not conducted quarterly as required. Deficiency cited. Physical plant was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, all in good condition with the exception of one window screen in Neighborhood 1 which was torn. Licensee will repair or replace and send a photo to CCL by 7/21/23 showing the correction. The facility maintains a comfortable temperature. The smoke detectors are hard wired and carbon monoxide detectors are placed in each neighborhood near the kitchenettes. Fire extinguishers are located throughout the facility, they were inspected on 04/21/23 and are charged in the green. There was one fire extinguisher, labeled as #19, which was not in the green, but rather the indicator was in the red to the left of the green. Licensee will get this inspected and send a photo to CCL by 7/21/23. There are no issues with Fire Clearance. Living rooms, dining rooms, and activity room furniture were checked and in good condition. The common rooms are clean, safe and sanitary. The courtyards of the facility have outdoor furniture, with shaded area for residents. Fountains are in compliance. Continued on 809-C. The kitchen area was sufficiently stocked with two-day perishable and seven-day non-perishables. The menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. The kitchen has three garbage cans, and two did not have lids. Licensee will place lids on the trash cans and send CCL photos by 7/21/23. No flies or pests were observed in the kitchen. Refrigerators are kept at 40 F or below and the freezer at 0 F degrees. Resident rooms are adequately supplied with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, nightstand and sufficient lighting for each resident. There is enough linen available to change weekly or more, if needed. Activity Room has sufficient activities for residents to stay active. At 11:50 am, LPA entered an open door to the kitchenette in the Activity Room and observed more than 5 pair of scissors in an unlocked drawer. Administrator immediately placed them in a locked drawer and will leave them there or add a lock to the "Office Supplies" drawer where they were observed. Technical violation issued. The Storage Rooms have sufficient amounts of personal hygiene products which are provided by the licensee and all cleaning products, toxins are stored and locked away inaccessible to residents in care. The bathrooms were checked for cleanliness and proper operation. The hot water temperature measured between 110.3 F and 112.0 F degrees in resident rooms 104, 111, 209, 212, 301, and 308. Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for Medical Assessments, Needs and Service plans, Signed Admission Agreements and Pre-appraisals. There were no issues with resident files reviewed. Planned activities are offered to residents in care. Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations/and current First Aid. Three staff have not completed the required first aid certification. Licensee will ensure staff complete this and send a copy to CCL by 7/21/23. The Administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate. Staff #1 (S1) was not associated with the facility during their entire time working in the facility. This poses an immediate health and safety risk to residents in care. Deficiency cited. Exit interview conducted, deficiencies cited, technical violations issued, and the report and appeal rights given.the state’s words, verbatim · CDSS document, Jul 14, 2023

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Chavez conducted a subsequent case management visit to deliver findings for an incident reported by the facility on 12/11/22. LPA met with Carolyn Stewart, LVN, and explained the reason for the visit. On 12/11/2022, the administrator emailed an Unusual Incident/Injury Report (LIC 624) to Community Care Licensing (CCL). The Incident Report stated that on 12/11/2022 at 4:25pm, staff entered the room of Resident #1 (R1) and found R1 in their bed unresponsive. Paramedics were called, and per the Administrator, R1 had committed suicide. On 12/13/2022, from 10:36am to 1:00pm, LPA Chavez conducted an unannounced visit to the facility to investigate the incident reported by the facility. LPA met with Kirk Klotthor, Administrator, and explained the purpose of the visit. From 10:40am to 11:50am, the LPA toured R1’s room, conducted interviews with Administrator and staff, and requested documents pertinent to the investigation. LPA determined further investigation was needed. On 12/14/2022, the case was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Maria Barragan. Investigator Barragan conducted interviews on 12/15/2022, at approximately 3:22pm, with Detective Dustin Phillips of the San Luis Obispo (SLO) Coroner’s office; on 12/19/2022, at approximately 4:08pm. and on 12/21/2022, at approximately 11:03am, contact with Lieutenant Chad Pfarr of the SLO Police Department; on 01/04/2023, at approximately 9:04am, with R1’s resident representative; on 01/12/2023, from approximately 10:40am to 1:55pm, with the Executive Director/Administrator, facility Licensed Vocational Nurse (LVN), staff and residents; on 01/17/2023, at approximately 1:01pm, with the SLO Long Term Care Ombudsman (LTCO); on 01/23/2023, from approximately 5:34pm to 5:55pm, with staff; on 02/05/2023, Continued on 809-C. at 11:20am, with staff; on 02/15/2023, at approximately 8:33am, and 03/10/2023, at approximately 8:56am, contact with the SLO Coroner’s office. In addition, the investigator reviewed facility file documents related to R1, SLO PD report, SLO County Sheriff’s Department report, Emergency Medical Services (EMS) report, 911 audio recording, medical records, and home health records. Based on the review of R1’s records, R1 was admitted to the facility in September 2022. R1’s primary diagnosis was dementia. R1 was also diagnosed with A-Fib, BPA, Diabetes II, and GERD. R1 had a history of being verbally abusive, depressed, and suicidal. R1 was able to communicate their needs, was ambulatory and able to take care of activities of daily living (ADLs) independently. R1 did not require special observation or night supervision and had no observable safety awareness deficits. R1 was cooperative, social, but expressed feelings of sadness. The facility was aware R1 had previously attempted to commit suicide, but R1 had been cleared by their physician prior to moving in. Per the Administrator, R1 did not exhibit signs of self-harm nor did they express thoughts of suicide during the time that they lived at the facility. A review of medical records revealed on 12/09/2022, another physician met with R1 to conduct a cognitive/functional evaluation as resident expressed wanting to move from the dementia unit to assisted living. R1 admitted he had been severely depressed, but only for a few months after their suicide attempt prior to moving into the facility. Based on the assessment, the physician did not see any signs of dementia and R1 had no suicide plan or thoughts of self-harm. According to the SLO County Sheriff’s report, on 12/11/2022, at approximately 4:42pm, Deputy Knowles was dispatched to the facility for a coroner investigation. Upon arrival, the Deputy met with SLO Police Department law enforcement personnel. Upon entering R1’s room, he observed R1 lying supine on a twin bed. R1 had a plastic bag over their head that was drawn closed with a blue cord around their neck. R1’s feet were bound together with a belt and R1’s hands were bound with a black cord behind their back. The autopsy and CT scanned performed on R1 revealed no signs of trauma or foul play noted. Facility staff advised they had seen R1 walking around the facility at approximately 1:00pm. The facility med-tech entered R1’s room at approximately 4:25pm and found R1 and called 911. Continued on 809-C. SLO Fire EMS responded to the facility but noted that R1 was already dead. R1 was pronounced dead at 4:36pm due to rigor mortis. Multiple facility staff were interviewed. It was reported that R1 had tried to commit suicide before but failed and called 911 for assistance. After that attempt, R1’s resident representative placed R1 at the facility where they resided since 09/20/2022. Facility staff stated R1 was not happy living at the facility because R1 felt they did not belong in a facility for residents with dementia. R1 was high functioning and mobile, unlike other residents in the facility. Based on the totality of the investigation, statements obtained, R1’s prior suicide attempt, no evidence of foul play or trauma to R1’s body, and a suicide note found on R1’s laptop written on the day R1 died, it was determined by the investigating law enforcement personnel that R1 had likely committed suicide. The autopsy and CT scan performed on R1 revealed no signs of trauma or foul play. Based on statements from facility staff, LTCO, and a review of medical records, R1 was high functioning, and R1’s needs were met. R1 was depressed but did not express thoughts of hurting self. R1’s resident representative stated facility staff took great care of R1 and R1’s health improved during the time that they lived at the facility. R1’s resident representative stated R1 was determined to kill self and it was no one’s fault. No citations will be issued at this time. Exit interview conducted and report given.the state’s words, verbatim · CDSS document, May 18, 2023

Allegation investigated: Staff not meeting residents care needs.

On 9/14/22 at 2:05 pm, Licensing Program Analyst (LPA) Chavez visited the facility to deliver final findings on a complaint investigation for the allegation listed above. LPA met with Kirk Klotthor, the facility administrator and explained the purpose of today’s visit. On the allegation “Staff not meeting residents care needs,” the complainant was concerned that the facility had been short-staffed for the past few months and that “multiple residents needs are not being met.” To investigate, LPA interviewed staff and witnesses. On 9/13/21 between 11:40 am and 1:54 pm, LPA interviewed Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), Staff #4 (S4), Staff #5 (S5), Staff #6 (S6), and Staff #7 (S7). S1 says the facility has a high employee turnover and that currently, there are “3-4 newbies and 5-6 veterans.” S2 says, “we could have more concierge.” S3 states that the “facility is short-staffed” and explains that there are “18 residents and 2 caregivers and 1 concierge.” Continued on 9099-C. Substantiated S3 says that residents have higher needs and there are “four heavy wetters who need changing every hour, others who need changing every two hours, and two residents who need a two-person assist.” S4 reports that there are two caregivers and one concierge per neighborhood and that “one to two times per month, we need more concierge in events.” S4 further explains that “At times, it is hectic, and we need more people.” S5 says there are “16-18 residents, 3 PCAs, and 1 concierge.” S5 explains that “3-4 staff work double shifts almost every day.” S6 says they work double shifts 2-3 times each week and that “lately it’s been worse.” S6 describes the situation, saying “new people quit quickly.” S7 explains that there are “a lot of people working double shifts since January 2021, at least 2-3 staff working double shifts daily.” On 9/17/21 at 3:07 pm, LPA interviewed Witness #1 (W1). W1 says that they had to “train the staff on mom’s needs, i.e. changing her (diaper) regularly, feeding her properly and feeding her regularly, turning her, showering her.” W1 stated that they “were not taking care of her due to a shortage in staff, new staff not being trained fully, and too few caregivers to get the job done.” On 7/21/22 between 2:15 pm and 2:59 pm, LPA interviewed Staff #8 (S8) and Staff # (S9). S8 says regarding incontinent needs that “It’s happened (residents not getting changed) about three times in the past 10 years.” S9 says they observed “Two staff who did not attend to residents’ toileting needs for more 30 minutes.” S9 further explains that “Staff are tired from working double shifts, and sometimes they don’t tend to residents’ needs.” On 7/22/22 between 9:55 am and 10:45 am, LPA interviewed Staff #10 (S10) and Staff #11 (S11). S10 reports that it is discussed with staff in crossover meetings. S10 says they do not know of any staff who had problems with changing residents’ diapers. S11 says “It happens sometimes. Staff may be helping other residents,” and S11 says they do not recall any staff in particular who did this. On 8/11/22 at 1:22 pm, LPA spoke with Witness #2 (W2). W2 says that their mother is “Typically is taken care of, however, her teeth bothered her, and staff don’t really assist with brushing her teeth.” W2 explains “Her hair looks terrible. Staff does a great job considering I don’t think they have enough people.” Based on the evidence obtained, the allegation “Staff not meeting residents care needs” is deemed Substantiated at this time. Interviews reveal that there was a staffing shortage, and residents were not being cared for in a timely manner. Deficiency cited on 9099-D. Exit interview conducted, deficiency cited, and a copy of the report and appeal rights emailed to the administrator. On 9/17/21 at 3:07 pm, LPA interviewed Witness #1 (W1). W1 says their mother “has not had any falls, bruises, or skin tears while at the facility.” On 8/11/22 between 10:50 am and 1:22 pm, LPA interviewed Witness #3 (W3) and Witness #4 (W4). W3 says “Mom has fallen a couple of times and both times, staff called W3 immediately.” W4 says “As people age, people fall.” W4 says “Staff know the residents who need assistance. My sister hasn’t had any falls.” On 9/12/22, LPA reviewed the facility’s incident reports for falls between September 2020 and September 2021. There were twenty-five (25) falls, an average two (2) per month. Skin tears were noted on two of the incident reports. Based on evidence obtained, the allegation “Staff not supervising residents resulting in fall sustaining bruises,” is deemed Unsubstantiated at this time. Interviews and records review indicate that residents did not have an unusually high number of falls prior to the complaint, and bruising was not a significant factor mentioned in interviews. There does not appear to be a lack of supervision at this time nor an excessive amount of falls given resident medical conditions. On the allegation “Staff left residents in soiled clothing for extended period of time resulting in rashes,” the complainant’s concern was that “multiple residents are left in soiled diapers for up to 5 to 6 hours resulting in rashes.” To investigate, LPA interviewed the staff and witnesses. On 9/17/21 at 3:07 pm, LPA interviewed W1. W1 says when their mother first arrived at the facility, W1 had to “train the staff on mom’s needs, i.e. changing her (diaper) regularly.” W1 says “now, she is being taken care of.” On 9/13/21 between 12:20 pm and 12:30 pm, LPA interviewed Staff #4 (S4) and Staff #5 (S5). Both staff say they have never seen rashes on residents. On 7/21/22 between 1:34 pm and 2:59 pm, LPA interviewed three staff. All three staff reported that some residents may have been left in soiled clothing for an extended period of time but did not indicate that residents received rashes from this. On 7/22/22 between 9:55 am and 10:45 am, LPA interviewed two staff. Staff say they hadn’t witnessed a problem. They say residents sometimes sit in soiled clothing for an extended period of time, however, no rashes were reported. Continued on 9099-C Based on the evidence obtained, the allegation “Staff left residents in soiled clothing for extended period of time resulting in rashes,” is deemed Unsubstantiated at this time. There is no evidence to suggest residents were acquiring rashes, however, the facility was cited on 8/25/22 for residents being left in soiled clothing for an extended period of time. On the allegation “Food service not provided to residents,” the complainant was concerned that “residents are not provided dinner and are put to bed at 6:00 – 6:30 pm.” To investigate, LPA interviewed staff and witnesses. On 9/13/21 between 12:08 pm and 1:54 pm, LPA interviewed Staff #3 (S3), S4, S5, S6, and S7. S3 says they “always make a sandwich in the kitchen and place it in the refrigerator, if a resident’s not there to eat.” S3 explains that there are extra snacks available to residents and that the common areas have water pitchers and coffee available on the kitchen counters. S3 says sometimes they feed residents in bed. S4, S5, S6, and S7 say that if a resident misses a meal, staff put the resident’s plate of food in the refrigerator with the resident’s name and date and say it is saved for the resident to eat later. Staff said that residents occasionally go to bed early, but that is not typical. On 9/13/21 at 11:35 am, LPA toured the facility. LPA observed food service to be adequate. The kitchen was fully stocked with food, and staff were preparing and delivering meals to resident neighborhoods. Based on the evidence obtained, the allegation “Food service not provided to residents,” is deemed Unsubstantiated at this time. Interviews indicate that staff are setting aside resident meals, if they are not available at meal time, and food is provided to residents. Exit interview conducted and the report emailed to the administrator.the state’s words, verbatim · CDSS document, Sep 14, 2022 · control 29-AS-20210907122144

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 15, 2022

87468.1(a)(2) 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 was not met as evidenced by: Based on interviews, the facility did not ensure that adequate personal hygiene measures were in place to keep residents healthy which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 14, 2022

Plan of correction: Administrator will send a written commitment to CCLD outlining plans to maintain staffing levels appropriate to meet the needs of persons in care. Administrator will send a written commitment to CCLD to send updated Personnel Reports (LIC 500) monthly (due first of each month) to CCLD through 12/31/22. Administrator will send the (2) written commitments to CCLD by 9/15/22.

Allegation investigated: Facility staff did not treat resident with respect

On 8/25/22 at 11:50 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced complaint investigation visit to the facility listed above. LPA met with Kirk Klotthor, Executive Director/Administrator and explained the purpose of the visit. On the allegation “Facility staff did not treat resident with respect,” the complainant was concerned that there was a Staff #7 (S7) who was "purposefully antagonize Resident #1 (R1) to make them agitated so the S7 member can call for a PRN to sedate the resident." To investigate the allegation, LPA interviewed staff and attempted to interview witnesses, and reviewed records. Continued on 9099-C. Unsubstantiated On 7/21/22 between 1:34 pm and 2:59 pm, LPA interviewed Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3). S1 and S2 they had no knowledge of the incident. S3 says they witnessed Staff #7 (S7) “antagonize R1, go up to R1 and look R1 in the eyes, stare at R1, and use mannerisms to get a negative reaction.” S3 says they witnessed this “One or two times, mid-morning and at lunch time.” S3 says they reported this to the Wellness Coordinator shortly after the incident. On 7/22/22 between 9:55 am and 10:45 am, LPA interviewed Staff #4 (S4) and Staff #5 (S5). S4 and S5 say they did not witness any staff being disrespectful to residents. On 8/19/22 at 10:04 am, LPA attempted to interview Witness #6 (W6) who may have had knowledge of the alleged incident. At the time this report was written, LPA did not hear back from W6. On 8/22/22 at 11:55 am, LPA attempted to interview former Staff #7 (S7) who alleged to have disrespected R1. At the time this report was written, LPA did not receive a callback from S7. On 8/22/22 at 1:03 pm, LPA spoke with Staff #5 (S5). LPA requested a copy of the incident report submitted by S3. S5 states that there are “No records of incidents with S7.” S5 explains that “If there were a complaint, it would have gone to the wellness coordinator which at the time was Staff #8 (S8) and now Staff #9 (S9).” On 8/24/22 at 2:04 pm, LPA spoke with S9. S9 states they don’t “Have access to records,” that staff only verbalize incidents to S9. At 2:09 pm, LPA spoke with the Administrator. Administrator states that “We don’t have a document for staff to submit incidents, it’s only a verbal statement.” He states that S7 had no write-ups. At 3:45 pm, LPA reviewed the records of staff who had been counseled from January to September 2020. S7 had not been written-up. Based on the evidence obtained, the allegation “Facility staff did not treat resident with respect,” is deemed Unsubstantiated at this time. There is insufficient evidence from interviews and documentation to determine whether S7 had been disrespectful to R1. Exit interview conducted and a copy of the report emailed to the administrator.the state’s words, verbatim · CDSS document, Aug 25, 2022 · control 29-AS-20200923102912

Allegation investigated: Facility staff did not assist residents with hygiene needs Residents were left in soiled clothing for an extended period of time

On 8/19/22 at 2:24 pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced complaint investigation visit to deliver final findings to the facility listed above. LPA met with Kirk Klotthor, Executive Director/Administrator and explained the purpose of the visit. On the allegations “Facility staff did not assist residents with hygiene needs” and “Residents were left in soiled clothing for an extended period of time,” the complainant’s concern was that staff were not assisting residents with showering, brushing teeth, or basic grooming. Complainant states that “residents have greasy hair, body odor, and wear the same clothes for several days.” Additionally, the complainant says residents are left in soiled clothing or briefs for an extended period of time. To investigate the allegations, LPA interviewed the staff and witness. Continued on 9099-C. Substantiated .On 7/21/22 between 1:34 pm and 2:59 pm, LPA interviewed Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3). S1 says “I’m not going to say we’re perfect, but it’s happened about three times in the past 10 years.” S2 says they observed “Two staff who did not attend to residents’ toileting needs for more 30 minutes.” S2 further explains that “Staff are tired from working double shifts, and sometimes they don’t tend to residents’ needs and they take naps.” S3 says they noticed “from time to time residents who had bowel movement accidents.” S3 says this topic was discussed in crossover meetings, and S3 says “If a manager told staff to change a resident’s diaper, they would change it, but if anyone else told staff, they would wait to change the diaper.” S3 did not specify how long staff waited. On 7/22/22 between 9:55 am and 10:45 am, LPA interviewed Staff #4 (S4) and Staff #5 (S5). S4 reports that it is discussed with staff in crossover meetings. S4 says they do not know of any staff who had problems with changing residents. S5 says “It happens sometimes. Staff may be helping other residents,” but S5 says they do not recall any staff in particular who did this. On 8/11/22 at 1:22 pm, LPA spoke with Witness #4 (w4). W4 says that their mother is “Typically is taken care of, however, her teeth bothered her, and staff don’t really assist with brushing her teeth.” W4 explains “Her hair looks terrible. Staff does a great job considering I don’t think they have enough people.” Other than these instances, W4 says they have had a really good experience with the facility. Based on the evidence obtained, the allegations “Facility staff did not assist residents with hygiene needs” and “Residents were left in soiled clothing for an extended period of time” are deemed Substantiated at this time. Interviews reveal that there were occasions where staff were not assisting residents with basic hygiene needs including changing diapers in a timely manner. Deficiency cited on 9099-D. Exit interview conducted, deficiency cited, and a copy of the report and appeal rights emailed to the administrator. On 9/25/20 at 2:59 pm, LPA interviewed Kirk Klotthor, Administrator. Administrator said the facility has a “standard program for training” new employees. He explains they start with learning the program, then shadowing. He was unsure how long the shadowing took place. On 7/21/22 between 1:34 pm and 2:59 pm, LPA interviewed S1, S2, and S3. S1 says “Caregivers may give information on a resident to med-techs, but I’ve never seen or heard someone giving medications that was not trained.” S2 and S3 say they “do not have any knowledge of this.” On 7/22/22 between 9:55 am and 10:45 am, LPA interviewed S4 and S5. S4 states that “Caregivers don’t touch meds, they only take care of residents. Med-techs do medical assessments, if residents have a wound or skin tear. They take care of it or wait until the LVN gets to it.” S5 reports that “If a nurse is not in the facility, med-techs will assess a resident fall. Any unwitnessed falls, staff always call emergency services.” S5 says that the LVN is required to do an assessment, if they’re in the building and when they’re not there, med-techs do the assessment.” On 8/11/22 between 10:50 am and 1:22 pm, LPA interviewed W1, W2, W3, and W4. W1 relays that “For the most part, everyone I’ve met is trained and real nice. One staff didn’t seem adequately trained to answer my questions when my mom had head lacerations.” W1 says they spoke with staff about preventing injuries, and staff talked about the possibility of using restraints.” W2 reports they have never seen a problem. They say “If I have questions, I go to the wellness room or call and talk to a med-tech.” W2 says “Covid was not good to the old people. Visits were limited.” W3 comments that staff are “mostly trained” and says “It’s about being positive and they (staff) are that way in situations where someone could get discouraged, for example, somebody who’s changing residents’ diapers several times a day.” W4 states that staff “Need more training” and describes a situation where their mom was in a wheelchair. W4 says “Staff brought her out in her wheelchair without feet support. This is a no, no. She could slip out.” W4 says they have had to remind staff about this. W4 speaks of a time when “Mom’s garbage can had a dirty diaper in it and there was poop on the side of the toilet. The room smelled badly. Staff dealt with right away once I mentioned it. Chalk it up to not really caring. Generally, staff is responsive and responsible.” On 8/18/22 at 10:15 am, LPA interviewed W5. W5 says “Staff is qualified, the ones I see, but they need more staff.” Continued on 9099-C. On 8/19/22, LPA reviewed the facility’s Medical Emergencies policy which states “Caregivers summon 911 should a resident exhibit signs and symptoms of a medical emergency.” Additionally, it says “The community summons emergency medical services by calling 911 when the resident exhibits signs and systems of distress and/or emergency condition.” Several examples of conditions are listed where “the community” addresses these situations. On the allegations “Facility staff are not properly trained,” and “Facility staff who are not appropriately skilled professionals are conducting medical assessments,” are deemed Unsubstantiated at this time. Interviews and records review reveal that only med-techs and LVNs are dispensing medications and providing medical care. On the allegation “Residents are sustaining multiple falls,” the complainant’s concern was that there had been a “high number of unattended falls" at the facility. To investigate, LPA interviewed the administrator, staff, and witnesses, and reviewed records. On 9/25/20 at 2:59 pm, LPA interviewed Kirk Klotthor, Administrator. Administrator says there are “a few” resident falls per month, possibly three (3) or more. He says he thinks there “aren’t that many falls.” He says minor falls are when “staff witnessed the fall and caught the resident.” He says when a fall is unwitnessed, the resident is “sent out” to the hospital. He says he completes about 10-15 incident reports per month. S1 reports “We have frequent falls because of dementia, but no more than usual in 2020. It was a crazy time, we were short staffed and it may have been a problem with more falls and staff leaving.” S2 says they did not think there were a lot of falls in 2020. S3 says residents have chair alarms and some staff do not want to check on them. S3 says “There are a handful of staff who were good about checking on residents and that the new, inexperienced staff didn’t care to follow residents with a fall risk down the hall.” S3 says they have seen residents fall because staff were not around to assist.” S3 further explains that “Residents don’t want to use their walkers or don’t like being touched so now caregivers can be close by and residents still fall.” S3 also reports that “Staff are on their phones too much and not paying attention to residents.” Continued on 9099-C. S4 says that in 2020, they don’t remember a lot of falls. S4 says they feel like there are “more falls now.” S4 explains residents have chair alarms so staff know when residents are getting out of their chairs. Staff does garden checks every 30 minutes where they go out to the garden and outdoor patios to check on residents. S4 explains that there are three caregivers and one concierge in each neighborhood, and that the concierge watches the common area, helps with resident falls, and checks on residents in the garden.” S4 says “Residents sometimes ask if they can go outside and this helps notify staff where residents are.” S5 says they believe there are the same number of falls now as in 2020 and that there are more falls outside now due to good weather. W1 says that their mom had nine unwitnessed falls in 2022. W1 explains that “Staff was trying to take a blanket from her and it ended up in a fall.” W1 also explains that “Mom went through a spell of falling for no reason.” W2 says “Mom has fallen a couple of times. One time she hurt her arm.” W2 says that both times, staff called W2 immediately. W2 comments that their mom’s evaluations state that she’s a fall risk. W2 says “As people age, people fall. I took her for a drive and after 2 hours in the car, she’s exhausted, a bit stumbling, and losing her footing.” W3 says “Staff know the residents who need assistance. My sister hasn’t had any falls.” W4 says their mom fell twice. W4 states that staff “Didn’t remember that she couldn’t walk. Staff sometimes forget to put her guard rails up. They called and let me know as soon as it happened. I checked on her the next day and she was fine.” W5 says their mom “Falls quite a bit” and describes that “A couple of weeks ago, she fell four days of the week.” On 8/18/22, LPA reviewed the facility’s incident reports for falls between January and September 2020. In this time period (9 months), there was a total of seventeen (17) falls, an average of 2 per month, 8 attended and 9 unattended. The average census was 53. In comparison, the facility had thirty (30) falls in the previous 9 months (April to December 2019), an average of 3.3 falls per month with an average census of 61, 11 attended and 19 unattended. The facility had a 13% decrease in residents and a 43% decrease in the number of falls from January to September 2020 than from the previous 9 months. Based on evidence obtained, the allegation “Residents are sustaining multiple falls,” is deemed Unsubstantiated at this time. Interviews and records review indicate that residents did not have an unusually large quantity of unattended falls during the time period of concern. Exit interview conducted and a copy of the report emailed to the administrator.the state’s words, verbatim · CDSS document, Aug 19, 2022 · control 29-AS-20200923102912

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Aug 22, 2022

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 was not met as evidenced by: Based on interviews, the facility did not ensure that adequate personal hygiene measures were in place to keep residents healthy which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 19, 2022

Plan of correction: Administrator will read the regulation and submit a Statement of Understanding to CCL by 8/22/22. Administrator will schedule Personal Rights training with all staff by 8/22/22 and send CCL a copy of the training sign-in sheet by 8/29/22.

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: Facility staff withheld water from residents

On 8/11/22 at 10:24 am, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced complaint investigation visit to the facility listed above. LPA met with Kirk Klotthor, Executive Director/Administrator and explained the purpose of the visit. On the allegation “Facility staff withheld water from residents,” the complainant’s concern was that there was a staff who was withholding water from residents because the staff did not want to change residents’ diapers. To investigate the allegation, LPA interviewed the administrator, staff, and family members of residents. On 9/25/20 at 2:59 pm, LPA interviewed the administrator. Administrator explains that all three neighborhoods have filtered water at each kitchen in the neighborhood and residents are able to get water and food “pretty much.” Continued on 9099-C. Unsubstantiated On 7/21/22 between 1:34 pm and 2:59 pm, LPA interviewed three staff, Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3). S1 says “this is not true. Residents are being given water.” S1 says they are a big advocate for abuse and they would report it. S2 says they are “not aware of this.” S3 says S3 heard about a staff withholding water from a resident, but didn’t observe it and didn’t know the staff person’s name nor resident’s name. S3 says “maybe water wasn’t pushed as much as it should be, but Wellness pushed me to give water to residents.” S3 reports that during meal times, some staff wanted to finish fast and push residents into the common areas. S3 says “Dementia residents don’t know they need water so it’s necessary to push residents to drink water. Some staff offered water, but didn’t push residents to drink.” On 7/22/22 between 9:55 am and 10:45 am, LPA spoke with Staff #4 (S4) and Staff #5 (S5). S4 says there is “always water and cups on dining tables and we offer residents water every hour.” S4 says they don’t remember any staff refusing to give water to residents. S5 says they “feel water is more important than food.” S5 explains that “Residents need water at meals and in between” and that S5 ensures staff knows to offer residents water several times throughout the day, however, this is “not documented.” S5 describes that “residents need water, just like you and I like to have water several times throughout the day.” S5 says they do not know of any staff who withheld water from residents. On 8/11/22 between 10:50 am and 1:22 pm, LPA spoke with Witness #1 (W1), Witness #2 (W2), Witness #3 (W3), and Witness #4 (W4). W1 says they have never seen staff withholding water from residents. However, W1 says that they “bring water bottles to mom, she drank a lot.” W1 reports that they made a complaint to Wellness that W1’s mother was not drinking an adequate amount of water. W1 says staff told W1 that “staff didn’t have a routine for when they offer residents water” and said they would try to give her mom more water. W1 explains that “Every time I offer my mother more water, she drinks it.” W1 says that W1’s mother was hospitalized recently and was found to have severe hydration. W1 says staff told W1 that they were “giving her food with higher water content.” W1 says they have checked twice since then and talked with two different staff, and Wellness gave W1 no indication as to how often they would be giving W1’s mother water. W1 requested that Wellness offers W1’s mother water hourly. W2 says they have not witnessed this and has ‘no complaints” against the facility. W2 says “They take very good care of my mother.” W3 says they “Have not experienced staff not giving residents water.” W3 says their sister is “never dehydrated and staff always give her enough water.” W3 says their impression is that staff are really honest and my sister is really well taken care of.” W4 says they have never experienced staff not giving water to residents. W4 explains “I believe it’s important to give water several times a day. When I visit, they (staff) always ask if we want something to drink.” Continued on 9099-C. Based on the evidence obtained, the allegation “Facility staff withheld water from residents,” is deemed Unsubstantiated at this time. Interviews reveal that staff are offering residents an adequate amount of water. Exit interview conducted and the report emailed to the administrator.the state’s words, verbatim · CDSS document, Aug 11, 2022 · control 29-AS-20200923102912

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility staff are not properly supervising residents

On 8/4/22022 at 11:05 am, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced complaint investigation visit to the facility listed above. LPA met with Administrator Kirk Klotthor, Executive Director/Administrator and explained the purpose of the visit. On the allegation “Facility staff are not properly supervising residents,” the complainant’s concern was that there was an incident where two residents were “missing” in the building and it was not noticed until two Life Enrichment assistants looked for them for an activity. To investigate, LPA interviewed the administrator and staff. On 9/25/20 at 2:59 pm, LPA interviewed the administrator. Administrator says there are 80 staff total and 3 caregivers in each neighborhood which has about 17 residents per neighborhood. He says each resident has a “call system” and that it is “obvious if they need attention.” Continued on 9099-C. Unsubstantiated On 7/21/22 between 1:34 pm and 2:59 pm, LPA interviewed three staff. Staff #1 (S1) states they have never observed a situation where staff were not supervising residents. Staff #2 (S2) says staff are required to do “garden checks” explaining that staff are “to go to the garden and make sure residents are okay.” S2 says they have not observed staff “not checking on residents.” Staff #3 (S3) states that “some residents would go into other residents’ rooms. If a resident got lost, it was my job to go look for them.” S3 states that staff are required to do garden checks every 30-45 minutes, inspecting the garden areas to ensure residents are okay. On 7/22/22 between 9:55 am and 10:45 am, LPA interviewed two staff. Staff #4 (S4) says they do not know of any instances where staff were not supervising residents. Staff #5 (S5) states “Staff do garden checks once an hour or more frequent, if possible. I have never heard or knew of any staff who weren’t taking care of residents.” S5 explains that residents are allowed to walk around in the garden unsupervised. Based on evidence obtained, the allegation “Facility staff are not properly supervising residents,” is deemed Unsubstantiated at this time. There is no evidence that staff are leaving residents unattended for lengthy periods of time nor that residents’ needs are not being met. Exit interview conducted and the report emailed to the administrator.the state’s words, verbatim · CDSS document, Aug 4, 2022 · control 29-AS-20200923110447

Allegation investigated: Facility Administrator is not at the facility a sufficient number of hours.

On 8/4/22022 at 11:05 am, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced complaint investigation visit to the facility listed above. LPA met with Kirk Klotthor, Executive Director/Administrator and explained the purpose of the visit. On the allegation “Facility Administrator is not at the facility a sufficient number of hours,” the complainant’s concern was that the facility administrator is at the facility about 16-20 hours per week and is typically out of the building running personal errands. To investigate the allegation, LPA interviewed the administrator and staff. On 9/25/20 at 2:59 pm, LPA interviewed Kirk Klotthor. Administrator states that he works at Village at Sydney Creek full days on Mondays and Wednesdays and four hours on Fridays, then works at Garden Creek full days on Tuesdays and Thursdays and four hours on Fridays. He said sometimes his schedule changes “depending on what comes up.” He explains that the other administrator, Heather Chapman, is an on-call employee and that Laura Green, Life Enrichment Director, works Saturdays. Continued on 9099-C. Unsubstantiated On 12/22/20 at 11:53 am, LPA interviewed Staff #6 (S6), a management employee. S6 states that the administrator and wellness coordinate are not available on weekends. S6 says the LVN is the possible back-up on weekends; however, S6 believes “there is a lack of supervision.” S6 recalls a time when the Vice President of The Villages showed-up for a meeting with the administrator and waited 35-40 minutes for him to arrive. On 7/21/22 between 1:34 pm and 2:59 pm, LPA interviewed three staff. Staff #1 (S1) says that “Every other day he goes to Garden Creek or as needed when there’s a problem. He’s reachable. Even on weekends, he’ll answer maybe just a little later.” Staff #2 (S2) says “If his office is open, he is here.” S2 says they do not see the administrator in the afternoon. S2 voices “He needs to be here to know what’s going on, that we need more staff.” S2 further states that it would be better if he was here all the time, and not split between Sydney Creek and Garden Creek. Staff #3 (S3) states that they do not see the administrator very often because S3 works in the facility’s neighborhoods and don’t spend much time outside the neighborhoods. S3 says they “saw Kirk about one to two times per week. I knew he was the executive director, but didn’t know him and only spoke to him a couple of times.” Staff #4 (S4) says they don’t notice the hours the administrator is in the building. Staff #5 (S5) says “If he’s not here, he answers his phone, he calls or texts. The only time he’s not available is when he’s on vacation.” S5 explains that “The facility has a strong, capable management team who works really well together and would be strong regardless of whether Kirk was the Executive Director or not.” Based on the evidence obtained, the allegation ““Facility Administrator is not at the facility a sufficient number of hours,” is deemed Unsubstantiated at this time. The administrator appears to be in the facility at minimum the required hours. However, based on staff comments, there is evidence to suggest the facility administrator should be in the building more hours to properly communicate with staff on the facility’s needs. Technical assistance is being given to educate on the requirement for administrator hours.the state’s words, verbatim · CDSS document, Aug 4, 2022 · control 29-AS-20200923102912

Type of visit: Case Management - Deficiencies

On 8/4/22022 at 11:05 am, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced complaint investigation visit to the facility listed above. LPA met with Administrator Kirk Klotthor and explained the purpose of the visit. On 7/28/2022 at 10:35 am, LPA visited the facility to investigate a complaint. During the investigation, it was found that the facility had a fire in the laundry room in July 2020 and it was not reported to CCL. LPA interviewed staff who stated the fire was due to a faulty dryer and that the sprinkler system put out the fire immediately. Staff explained that the fire department was called, however, they did not need to put out the fire because the sprinkler had already diffused it. Maintenance staff stated they contacted the Executive Director and reported the incident shortly after it occurred. Staff stated there was no threat to residents in care. On 7/29/22 at 6:02 pm, Vice President Lisa Hulse informed LPA that there was no Incident Report (LIC 624) on record for the fire. The facility did not report an incident that is required to be reported to CCL, specifically “fires and explosions.” Deficiency cited on 809-D. Exit interview conducted, deficiency cited, and a copy of the report and appeal rights emailed to the Vice President and Administrator.the state’s words, verbatim · CDSS document, Aug 4, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(3) · Plan of correction due date: Aug 4, 2022

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (3) Fires or explosions which occur in or on the premises shall be reported immediately to the local fire authority; in areas not having organized fire services, within 24 hours to the State Fire Marshal; and no later than the next working day to the licensing agency. This is a potential safety hazard to residents in care. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not report a fire incident to CCL.the state’s words, verbatim · CDSS document, Aug 4, 2022

Plan of correction: Administrator has committed to reviewing the regulation listed above and writing a Statement of Understanding showing an understanding and commitment to adhering to the regulation from this point forward. The Statement will be sent to LPA by 8/08/22.

Type of visit: Required - 1 Year

On 8/04/22 at 1:54 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Administrator Kirk Klotthor and explained the purpose of the visit. LPA toured the facility with the administrator and observed the following: The facility has infection control signage at the front door and signage throughout the facility on handwashing, cough etiquette and use of masks. Upon entry to the facility, LPA was screened. Staff are wearing masks. The facility has soap and paper towels in resident bathrooms. The fire extinguishers (11) are located in the offices’ hallway, common area hall, kitchen (2), laundry room, and (2) in each of the three neighborhoods. The extinguishers are fully charged and were inspected on 6/2/22. Maintenance staff attempted to test the carbon monoxide detectors, however, the alarm did not sound. Administrator will follow-up with Alpha Fire to determine the most recent date the detectors were tested. Administrator will send documentation to this affect on or before 8/11/22 to LPA. At 2:40 pm, LPA conducted the Infection Control mitigation module with the administrator. No deficiencies cited. Exit interview conducted and report emailed to the administrator.the state’s words, verbatim · CDSS document, Aug 4, 2022

Allegation investigated: Facility staff are not conducting fire drills

On 7/28/22 at 10:35 am, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced complaint investigation visit to the facility above. LPA met with Lisa Hulse, Vice President, and explained the purpose of the visit. On the allegation “Facility staff are not conducting fire drills,” the complainant was concerned that the licensee has not had a fire drill in 18 months and reports that there was a real fire at the facility and “staff did not know what to do.” To investigate the allegation, LPA interviewed the administrator and staff, and reviewed records. On 9/25/20 at 2:59 pm, LPA spoke with Kirk Klotthor, Executive Director/Administrator. Mr. Klotthor reports there have never been any evacuations or fires, and that the last time they had a fire drill, he says “I don’t even remember.” He explains that the “maintenance guy does the fire drills.” Continued on 9099-C. Substantiated On 7/21/22 between 1:34 pm and 2:59 pm, LPA interviewed three staff. Staff say they have attended training on fire drills and there have been some impromptu fire drills. They state this happens between monthly and every 3-4 months. One staff stated “we have not had one this year.” Another staff stated they were not familiar with who was responsible for evacuating which residents. On 7/22/22 between 9:55 am to 10:45 am, LPA interviewed two staff. Staff report there are approximately three fire drills per year and that the maintenance manager conducts them. Further, that the maintenance manager takes staff around the facility and shows them were the fire extinguishers and exits are located. They state that on one occasion, the fire department came out to show them how to evacuate, and on another occasion, “the Alpha Fire guy came and did a demonstration with staff on putting out a fire.” On 7/28/22 at 11:00 am, LPA interviewed the Maintenance Manager who stated that a fire occurred in the laundry room of the facility in 2020. At 12:28 pm, LPA interviewed part-time maintenance staff who stated that there was a fire in the laundry room in July 2020. Maintenance staff does not remember the exact date and specifies that the Wellness Coordinator contacted them at 12:05 am on that day. Maintenance staff arrived at 12:20 am to find the fire department finishing up. Staff says the sprinkler above the dryer put out the fire. On 7/28/22 at 11:26 am, LPA reviewed the training sign-in sheets for fire drills. Between July 2019 and September 2020, fire drill training was conducted on 7/11/19, 11/14/19, 3/12/20, and 6/18/20. The first three trainings were conducted four months apart. LPA reviewed the staff schedule dated 9/24/20 which lists 83 staff, 41 of which are direct care staff. LPA compared this with the list of attendees for each training. At the 7/11/19 training, 14 out of 41 direct care staff attended (34% attendance); at the 11/14/19 training, 19 of 41 care staff attended (46% attendance); at the 3/12/20 training, 27 of 41 care staff attended (66% attendance); and, at the 6/18/20 training, 26 of 41 staff attended (64% attendance). Trainings were not attended by all direct care staff. Based on the evidence obtained, the allegation “Facility staff are not conducting fire drills,” is deemed Substantiated at this time. The facility did not conduct fire drills at minimum once every three months with, at minimum, all direct care staff on each shift attending the training as required with facilities caring for residents with dementia. Deficiency cited on the LIC 9099-D. Exit interview conducted, deficiency cited, and a copy of the report and appeal rights emailed to the Vice President and the Administrator.the state’s words, verbatim · CDSS document, Jul 28, 2022 · control 29-AS-20200923110447

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(I)(8) · Plan of correction due date: Aug 2, 2022

87705(I)(8) Care of Persons with Dementia: (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (8) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. This requirement was not met as evidenced by: Based on interviews and record review, the facility did not ensure that, at minimum, all direct care staff were trained on fire drills at minimum every three months which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 28, 2022

Plan of correction: Vice President has committed to ensuring fire drills are conducted at minimum every three months with at minimum all direct care staff. Attendance will be documented on training sign-in sheets. Vice President has read the regulation and submit a Statement of Understanding to CCL by 8/02/22. Vice President has agreed to discuss the requirements with management to ensure it is being taken care of.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff are not wearing masks while present in the facility

On 4/07/2022 at 5:09 pm, Licensing Program Analyst (LPA) Chavez conducted a 10-day unannounced complaint investigation. LPA met with Staff #2 (S2) and Staff #3 (S3) and explained the purpose of the visit. Regarding the allegation “Staff are not wearing masks while present in the facility,” the complainant’s concern was that two caregivers working in the facility were observed not wearing face coverings. To investigate the allegation, LPA interviewed a credible witness, the administrator and staff, and toured the facility. On 3/29/2022 at 1:35 pm, a credible Witness #1 (W1) observed Staff #4 (S4) in neighborhood one not wearing a mask while in the direct vicinity of residents in care. Staff #5 (S5) was also observed not wearing a face covering while working in the medication room. On 4/07/2022 at 5:09 pm, LPA arrived at the facility and was not screened upon entry or at anytime during the visit. Continued on 9099-C. Substantiated On 4/07/2022 at 5:15 pm, LPA interviewed Staff #1 (S1) who revealed that the receptionist is responsible for ensuring all staff and visitors wear masks upon entry, and when the receptionist is not present, management is responsible. LPA observed a central entry point for staff and visitors; however, there is access to the facility through the kitchen as well. LPA interviewed Staff #2 (S2) who stated that all staff are required to wear surgical masks and that “everyone is responsible” for making sure all staff are wearing a mask. S2 stated that the only time staff do not wear masks is when eating and drinking in the breakroom. S2 also said that staff take their masks off temporarily in the facility to get a drink. At 5:33 pm, LPA spoke with Administrator Kirk Klotthor by phone. Administrator says all staff and visitors are required to wear masks. The exception, he says, is when a resident does not understand staff, then staff will temporarily take their masks off when talking with residents. On 4/07/2022 at 5:35 pm, LPA toured the facility and observed all staff present wearing masks. Based on observations, the allegation “Staff are not wearing masks while present in the facility,” is deemed Substantiated. LPA interviewed credible witness and staff and made observations. The facility did not protect the personal rights of residents in care to be able to receive safe and healthful accommodations in that the facility staff failed to wear face coverings while providing care and supervision to residents in care and visitor was not screened upon entry. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions. Pursuant to Title 22, California Code of Regulations, the deficiency will be cited on 9099-D. Exit interview conducted, deficiency cited, a copy of this report and appeal rights emailed to Administrator.the state’s words, verbatim · CDSS document, Apr 7, 2022 · control 29-AS-20220330120349

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1 · Plan of correction due date: Apr 14, 2022

87468.1 Personal Rights. Residents have the right to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on observations, the facility failed to ensure staff were wearing face coverings which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 7, 2022

Plan of correction: Administrator will hold infectious control training, review and train staff on all recent PIN’s released for 2022, including mask-wearing mandated, and provide copy of training and staff signatures to CCL by 4/14/22.

Type of visit: Case Management - Deficiencies

At 11:05 am on 9/13/2021, Licensing Program Analyst (LPA) Chavez arrived at the facility to conduct a 10-day complaint visit. LPA informed Administrator Kirk Klotthor of the reason for the visit. During record review and interviews, LPA determined that the facility has five (5) staff currently employed who do not have fingerprint clearance. Administrator confirmed that Staff #1 (S1) was hired 8/09/21 and presently works in the facility from 7:00 am to 3:30 pm. S1 had already left for the day. Administrator phoned S1 and informed to not return to work until fingerprint clearance is obtained. Administrator confirmed that Staff #2 (S2) was hired on 8/06/21 and currently working 1:00 pm – 8:30 pm. Administrator stated that Staff #3 (S3) was hired on 8/23/21 and works 8:30 am – 5:00 pm, and that Staff #4 (S4) was hired on 9/01/21 and works 2:30 pm – 11:00 pm. Administrator promptly spoke with S2, S3 and S4, explained the situation, and asked S2, S3, and S4 to leave the premises immediately. S2, S3 and S4 left the facility and will return once they have obtained a criminal background clearance. Administrator stated that Staff #5 (S5) was hired on 8/10/21 and works 6:30 am – 2:00 pm. S5 was not working today. Administrator spoke with S5, explained the situation, and informed S5 that S5 can return once the fingerprint clearance has been obtained. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Civil penalties assessed in the amount of $2,500.00, $500 for each deficiency. Exit interview conducted, and today's report and civil penalties were reviewed and emailed to Administrator. Appeal rights issued.the state’s words, verbatim · CDSS document, Sep 13, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Sep 14, 2021

87355(e)(1) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department. The requirement was not met as evidenced by: Interviews and record review. S1, S2, S3, S4, and S5 do have a criminal background clearance. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 13, 2021

Plan of correction: Administrator agrees to provide a written declaration stating no staff will work at the facility until a criminal background clearance and association have been obtained. Declaration will be provided via email to LPA no later than end of business day, September 14, 2021.

Allegation investigated: Staff made inappropriate comments towards resident(s) in care

Licensing Program Analyst (LPA) De Lon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. LPA met with Lisa Hulse, VP of Operations and explained the purpose of the visit. During the investigation, LPA conducted interviews with staff on 07/28/2021 at 10:25 am, 11:11 am, 11:43 am, 12:51 pm, 1:41 pm, 4:01 pm, and on 07/29/2021 at 1:57 PM. LPA conducted interviews with witnesses on 07/29/2021 at 3:32 pm, 3:48 pm, 4:03 pm, 4:08 pm and 08/02/2021 at 12:47 pm. LPA reviewed records on 07/30/2021 at 5:00 pm and 08/02/2021 at 4:45 pm took tour of the facility Kitchen and food supply. LPA was unable to conducted interviews with residents due to cognitive awareness in the memory care (MC) facility. Continued 9099-C Substantiated On the allegation: Staff made inappropriate comments towards resident(s) in care. LPA interviewed staff 1 (S1), Staff 2 (S2), Staff 3 (S3), Staff 5 (S5) and Staff 6 (S6) revealed that some staff persons did talk to residents and say things that were not appropriate to say to or in front of a resident. S6 thought the staff’s intent was not to be harmful. S3, S5 and S6 revealed it may have been a culture issue as sometimes other languages were spoken in front of residents and it was not appropriate for the work place or the residents because some of the residents could not understand what was being said so it seemed rude to do in front of them. S6 revealed a staff was joking but that she didn’t laugh or come across to others that way so if you didn’t know the staff personally it might have come across as inappropriate. Based on the evidence this allegation is deemed substantiated at this time. Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to facility. On the allegation: Staff hit resident (s) in care. Based off Interviews with Staff 1 (S1), Staff 2 (S2), Staff 3 (S3), Staff 4 (S4), Staff 5 (S5), Staff 6 (S6) and Witness 1 (W1), Witness 2 (W2), Witness 3 (W3), Witness 4 (W4), and Witness 5 (W5), no hitting of residents by staff was ever observed. S1-S7 were trained to report any incident of abuse and if witnessed they would have reported the incident. W1-W5 stated they had never observed residents being hit by staff at any visits they made to the facility. Due to a lack of evidence this allegation is deemed unsubstantiated at this time. On the allegation: Staff handled resident(s) in a rough manner. LPA interviewed several staff , S1-S7 did not witness any accounts of staff handling residents roughly. Witnesses W1-W5 have never seen staff handle any resident in a rough manner. S1-S7 stated they are trained correctly to handle residents with proper care and trained techniques are used to provide added safety along with 2- person assist when needed. Due to the lack of evidence this allegation is deemed unsubstantiated at this time. On the allegation: Staff failed to assist resident in a timely manner after a fall. LPA interviewed S1-S7 and W1-W5 all interviews revealed falls do happen, but staff respond quickly to falls, medication-technicians (MT) are called immediately to assess, MT call 911 when needed and responsible parties are notified promptly. S1-S7 stated fall procedures are followed and it is all done in a timely matter. Due to the lack of evidence the allegation is deemed unsubstantiated at this time. On the allegation: Staff threatened resident in care. All interviews conducted with S1-S7 and W1-W5 did not reveal any staff were threatening to any residents in care. S1-S7 interviews revealed that staff were caring and did their jobs well. W1-W5 said staff that they came across during visits to the facility were doing a great job caring and meeting the needs of the residents. Based on the lack of evidence this allegation is deemed unsubstantiated at this time. Continued 9099-C On the allegation: Staff withheld food from resident(s) in care. Based on interviews conducted with S1-S7 the facility has plenty of food to feed residents, residents are given choices in meals, some residents are on a special diet due to being diabetic or lactose intolerant as well as needing food pureed or cut up into smaller chunks for swallowing. S2, S3, S6 stated the only time a meal would be taken away is if the resident was on a special diet and handed the wrong meal, but it would be replaced with another meal they could eat. S3 and S7 interview revealed if residents wanted to sleep or just didn’t want to eat at that time the staff would have the food wrapped to be given to them when they were ready. None of the interviews conducted revealed food was being withheld from residents. On 08/02/2021 at 4:45 pm, LPA toured the facility kitchen, observed the food supply, reviewed the menu records and choices available to the residents, everything was within regulations requirements. Based on the lack of evidence in this allegation it is deemed unsubstantiated at this time. On the allegation: Staff failed to ensure resident's shower water was a comfortable temperature. Interviews with S1-S7 all stated the PCA would run the water first, then check it before putting the resident inside the shower. S1, S4 and S5 stated they would ask the resident to check it with a hand or foot before putting their full body in the water and if a resident needed water adjusted staff would do that for them. W1-W5 stated they never observed showers being too hot or cold in temperature and none of the residents ever stated to W1-W5 that their shower or water temperature was a problem. Due to the lack of evidence this allegation is deemed unsubstantiated at this time. On the allegation: Staff assisted resident in an unsafe manner. The interviews with S1-S7 revealed staff were trained to assist residents in the safest manner, staff would ask for help when needed, and 2-person assists were conducted when needed. W1-W5 revealed no issues with staff assisting residents and observed it done safely when they were in the facility. Due to the lack of evidence this allegation is deemed unsubstantiated at this time. Exit interview conducted and copy of report emailed to Facility.the state’s words, verbatim · CDSS document, Aug 2, 2021 · control 29-AS-20191206084044

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 9, 2021

...(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews with staff the licensee did not comply with the regulations above as staff made inappropriate comments to resident in care, which poses an immediate personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Aug 2, 2021

Plan of correction: Administrator agreed to hold staff training on personal rights, communication with staff and residents, give staff examples of appropriate/inappropriate language in the work place and provide proof of trainings topics with staff signatures to CCL.