Springfield Place

Type of visit: Case Management - Annual Continuation

License Program Analyst's (LPA) Shannan Hansen arrived at 8:30 AM to complete an unannounced annual inspection and met with Stacy Vermeulen, Administrator. There is a total of 75 residents, with 2 on hospice. LPA conducted a sample review of five staff records at 9:00 AM on 10/5/2023 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received the additional training requirements as per Title 22 Regulations and H&S Code. LPA was presented with proof of CPR & 1st Aid certification; although 1 of 3 staff requiring 1st Aid certification was expired (see LIC809-D). Disaster Drills have been conducted quarterly in different shifts with the last one being conducted on 9/22/2023. For disaster preparedness facility has secured underground cables to connect to contracted generator placed in back of facility for fire season, 3 months out of the year. Stacy Vermeulen Administrator Certificate # 6059049740 provided proof pending. LPA reviewed staff records, centrally stored medication record, and conducted staff interviews to complete this annual inspection. LPA Hansen is requesting Licensee to update and submit the following documents to the SRRO by 10/22/2023: LIC 308 Designation of Facility Responsibility LIC 500 Personnel Record Copy of Administrator Certificate Proof of Liability Insurance Continue on LIC809-C The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..the state’s words, verbatim · CDSS document, Oct 5, 2023

Type of visit: Required - 1 Year

License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required 1-year visit of the facility. LPA was welcomed by front desk staff. Executive Director (ED) Stacy Vermeulen arrived shortly after for the visit. There is a total of 75 assisted living residents. There is 2 residents currently on Hospice. LPA toured the facility on 10/3/2023 at 8:35 AM with Executive Director (ED) Stacy Vermeulen; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 6/8/2023 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 5/31/2023. Every resident apartment has an individual smoke detector in addition to hard wired, and smoke detectors were found to be operational on today’s visit. LPA observed 3 out of 3 Carbon monoxide detectors that were found to be operational during the visit. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 109.7 degrees F and 117.3 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 11 resident’s bathroom faucets while touring facility on 10/3/2023 at 9:45 AM. The facility has no special care plan of operation and programming for residents with Dementia. Facility serves residents without dementia. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per Title 22 Regulations. There are special provisions made for individuals with special dietary needs. Facility keeps a variety of items on the menu, and facility makes residents aware at admissions agreement of residents having the responsibility over their own special dietary needs. Food is available for residents any time of the day. There is a daily activity schedule for residents. Toxins are stored in a locked housekeeping room. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms in resident’s rooms have a towel and soap. Continued on LIC809-C Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Resident’s at this facility are very independent and decorate their own apartments. A sample review of six resident records was conducted. LPA reviewed resident’s files at 12:15 PM on 10/3/2023 and learned that 6 out of 6 residents have an updated reappraisal/needs & care plan on file as well as medical assessments at this time as required by Title 22 Regulation. Medications were centrally stored in two locked medication carts in medication room at the facility. Facility has had an audit from Omnicare on 6/7/2023 and has provided a copy to the Department. LPA initiated a file review of five personnel files but were unable to complete. LPA was also unable to review medication and will return at a later date to complete annual inspection. No deficiencies cited during today's inspection.the state’s words, verbatim · CDSS document, Oct 3, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management inspection and met with Administrator Stacy Vermeulen. The purpose of this case management inspection is to follow up on an, SOC 341 submitted to Community Care licensing (CCL). CCL received a SOC 341 form on 11/17/2022 reporting on 11/11/2022 staff (S1) was viewed via video provided by resident's (R1)'s family to facility, to be impatient in approach and verbal cueing while providing care to R1. Facility removed S1 from shift on 11/12/22 and was terminated from facility. R1 was on hospice and passed away on 11/16/2022 due to cancer diagnoses. During today's inspection LPA conducted interviews, obtained records, and advised facility to submit a copy of police report when received. LPA will review information, conduct additional interviews and follow up with facility. No citation issued during today's visit.the state’s words, verbatim · CDSS document, Dec 2, 2022

Type of visit: Required - 1 Year

License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required – 1 yr. Infection Control inspection to this facility. LPA was welcomed by Stacy Vermeulen, General Manager/Administrator. There is a total of 81 residents at the facility with no residents currently on Hospice/waiver for 6. LPA toured the facility on 10/5/2022 at 9:00 AM with Administrator Stacy Vermeulen; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 6/1/2022 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 10/4/2022. Every resident apartment has an individual smoke detector in addition to being hard wired, and smoke detectors were found to be operational on today’s visit. LPA observed Carbon monoxide detectors to be operational during the visit as well. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Facility is in process of installing generator cable box in case of power outage to be used with a rental generator. Residents’ medications are centrally stored and locked in med room. Facility has a 30-day supply of medication for residents. The facility has no special care plan of operation and programming for residents with Dementia. Facility serves residents without dementia. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per Title 22 Regulations. There are special provisions made for individuals with special dietary needs. Facility keeps a variety of items on the menu, and facility makes residents aware at admissions agreement of residents having the responsibility over their own special dietary needs. Food is available for residents any time of the day. There are daily activities scheduled for residents: morning exercises 6 days a week, Bocce Ball, Bingo, live music and excursions outside of facility. Continue to LIC809-C Toxins are stored in a locked housekeeping room. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. Hot water temperature measured between 109.4 degrees F and 116 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 8 of 8 resident’s bathroom faucets. An electronic water heater was purchased in 2020. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Resident’s at this facility are very independent and decorate their own apartments. Infection Control: Facility has submitted mitigation program plan and Infection Control plan. Posters have been placed at facility. Facility has PPE supply stored in apartment 244 and in closet under staircase. Staff had required PPE training and N95 Fit Testing. LPA Hansen reviewed Licensing Information System (LIS) with Administrator Stacy Vermeulen who stated that it is correct and updated at this time. In addition, LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. In addition, facility has a designated area for visitors in the courtyard, private dining room, and in apartments. Residents also have available Facetime, Zoom, and telephone calls for visits. LPA was presented with proof of current CPR & 1st Aid certification for staff. Administrator Certificate is for Stacy Vermeulen #6059049740 Exp. 4/4/2023 All staff who do not have waivers have received COVID booster vaccinations. LPA discussed new AB 219 LGBTQ Elder Bill of Rights with Administrator No deficiencies cited during todays inspection LPA Hansen is requesting Administrator to update and submit the following documents by 10/17/2022: Continued on LIC809-C LIC 308 Designated LIC 309 Administrative Organization LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 610E-S Supplemental Emergency Disaster Plan for RCFE LIC 9020 Register of Facility Resident’s Copy of Control of Property Copy of Administrator Certificate Copy of Certificate of Liability Insurancethe state’s words, verbatim · CDSS document, Oct 5, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management inspection and met with Administrator Stacy Vermeulen & Health and Wellness Manager (HWM) Tracy Nava. The purpose of this case management inspection is to follow up on two self reported incident reports submitted to Community Care Licensing (CCL). LPA entered the facility and was screened at front desk with log in, COVID questions, and temperature checked. LPA is following up regarding a self reported Incident Report received on August 29, 2022 regarding resident (R1), who was found on floor next to bed on a routine two-hour safety check. R1 was very confused and combative and was sent out to Hospital. This was R1’s second incident, first was 7/31/2022 when R1 was returning to apartment after lunch. Staff (S1) found R1 on the hallway floor unresponsive with a pump/bruise on forehead bleeding. R1 was sent to hospital. LPA obtained documents and requested at return of R1 to facility, submit additional documentation and continue with two hour safety checks. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Sep 1, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Hansen conducted an unannounced case management and met with Administrator Stacy Vermeulen. The purpose of this case management inspection is to following up on a self reported incident report, SOC 341, submitted to Community Care Licensing (CCL). CCL received a self report incident report and SOC341 form on 7/13/2022 reporting on 7/5/2022 resident's (R1) family member notified facility R1 was missing $50 dollars from wallet (kept in night stand) and R1 also informed there was an additional $400 dollars missing from tea box in R1's kitchen cabinet. Administrator conducted internal investigation and obtained statements. Submitted reports cross reported to Petaluma Police Department and responsible party notified. LPA made copies of internal investigation notes, records, conducted interviews and made observations. Administrator agrees to inform LPA when investigation is complete and how facility is going to proceed regarding second incident of alleged stolen monies. There has not been any other like incident's in the facility since. No deficiencies cited during today's inspection.the state’s words, verbatim · CDSS document, Aug 16, 2022

Type of visit: Required - 1 Year

License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required – 1 yr. Infection Control inspection to this facility. LPA was welcomed by Stacy Vermeulen, General Manager/Administrator. There is a total of 70 residents with 1 resident currently on Hospice. LPA arrived at the facility and had temperature checked and logged by electronic system. All staff are temperature check and logged each shift and wear masks. LPA toured the facility on 10/14/2021 at 1:30 PM with Plant Operations Supervisor Joel Bruno; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 5/5/2021 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 9/1/2021. Every resident apartment has an individual smoke detector in addition to hard wired, and smoke detectors were found to be operational on today’s visit. LPA observed 2 out of 2 Carbon monoxide detectors that were found to be operational during the visit. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured between 113.1 degrees F and 116.2 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 8 of 8 resident’s bathroom faucets while touring facility on 10/14/2021 at 1:50 PM. An electronic water heater was purchased in 2020. The facility has no special care plan of operation and programming for residents with Dementia. Facility serves residents without dementia. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per Title 22 Regulations. There are special provisions made for individuals with special dietary needs. Facility keeps a variety of items on the menu, and facility makes residents aware at admissions agreement of residents having the responsibility over their own special dietary needs. Food is available for residents any time of the day. There is a daily activity schedule for residents. Continue to LIC809-C Toxins are stored in a locked housekeeping room. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Resident’s at this facility are very independent and decorate their own apartments. Infection Control: Facility has submitted a mitigation program plan that was approved on 4/5/2021. Posters have been placed at facility. Facility has PPE supply stored in apartment 244 and in closet under staircase. Residents’ medications are centrally stored and locked in med room. Facility has a 30-day supply of medication for residents. Some residents do wear masks inside the facility. Staff had required PPE training and N95 Fit Testing. LPA was presented with proof of CPR & 1st Aid certification for staff. LPA reviewed Licensing Information System (LIS) with Administrator who stated other than e-mail address that needs to be changed to SVermeulen@leisurecare.com all is correct. Disaster Drills have been conducted bi-annually with the last one being conducted 5/2021 and Fire Drills are conducted monthly. LPA advised facility to contact Sonoma County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. All required documents received from facility in the last few months & today There were no deficiencies cited at this timethe state’s words, verbatim · CDSS document, Oct 14, 2021

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Hansen & Fernandes-Goes conducted an unannounced case management – incident and met with Stacy Vermeulen - General Manager & via phone Kehley McKenzie - Health & Wellness Director. The purpose of the case management visit was to obtain additional information regarding recent incident report that was self-reported by the facility. LPAs obtained more information on SIR submitted to CCL on 8/11/2021 that occurred on 8/8/2021 regarding resident R1 incident report medication error. Facility staff S1 dispensed medication Norco 10MG-325MG tablets on 8/8/21 and gave resident R1 2 tablets at 12:38 AM. Per doctors orders on file dated 8/3/2021, Norco 10MG-325MG take 1 tablet by mouth every 12 hours as needed for pain. Facility uses an electronic MARs (Medication Administration Records) to track and allow med techs to follow doctor's orders. According with lead med tech Ermi interview staff will have a red target on electronic MARs if trying to give a medication in the wrong time or quantity. Staff S1 didn't follow doctor's orders when resident R1 requested 2 Norco by dispensing 2 Norcos at once. (see copies on file, LIC 809-D) Facility is conducting medication training including shadowing lead med tech, and will be assessing staff S1 before allowing to return as med tech. In addition, LPAs requested training and records for staff med tech S1, and learned that staff S1 was hired on 12/4/2020. Facility wasn't able to provide proof of initial medication training due to change of leadership in the facility per general manager Stacy V. and Kehley - Health & Wellness Director. (see staff records on file, LIC 809-D) The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Appeal of Rights Given.the state’s words, verbatim · CDSS document, Aug 18, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(c)(2) · Plan of correction due date: Aug 19, 2021

87465(a)(c)(2)Incidental Medical & Dental Care Services.Once ordered by the physicias the medication is given according to the physician's directions. This requirement isn’t met as evidenced by:Based on staff interview & incident report submitted to CCL on 8/11/2021 facility staff didn't comply w/section cite above by given resident R1 meds as ordered/prescribed by the Physician which poses an immediate health & safety risk to resident in care. LPAs learned that staff S1 dispensed medication Norco 2 10-325 tablets instead of only 1 every 12 hrs per doctor's orders dated 8/3/21 on file to R1 on 8/8/2021. (see copies on file)the state’s words, verbatim · CDSS document, Aug 18, 2021

Plan of correction: Facility to ensure that med techs will follow doctor's orders when dispensing medications. Facility to provide CCL with plan for S1 training by POC date of 8/19/21. In addition, facility to complete all training planned for staff S1 and submit topics, time, and dates to CCL by 9/1/2021 before allowing staff S1 dispensing medications alone.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.69 · Plan of correction due date: Sep 1, 2021

H&S 1569.69 Employees assisting residents with self-administration of medication; training requirements.This requirement is not met as evidenced by:Based on file review & interviews, facility didn't comply w/section cite above in 1 out of 1 initial med tech staff training records not on file which poses a potential health, safety, and personal rights risk to residents in care. LPAs requested records of training for staff med tech S1 during visit and were informed that facility has no proof of training on facility file for staff S1 at this time. Staff S1 was hired on 12/4/2020 according with staff file. There is no medication and shadowing proof of initialor continuing training on file.the state’s words, verbatim · CDSS document, Aug 18, 2021

Plan of correction: Facility to ensure that all staff at facility has required trainings on file according with their position. Facility to submit proof of initial training for staff S1 with dates, time, trainer according with Health & Safety Code by POC due date of 9/1/2021 in order to clear this citation.

Type of visit: Case Management - Incident

Licensing Program Analyst's Fernandes-Goes and Hansen conducted an unannounced case management and met with Stacy Vermeulen – General Manager. The purpose of the case management visit was to obtain additional information regarding incident report that occurred on 7/27/2021 for resident R1. LPAs interviewed Stacy V. General Manager and Kehley McKenzie – Health & Wellness Director, acquired more information and discussed regarding visitors sign in & out when residents are not allowed to be out in the community unassisted. In addition, LPAs are requesting facility written program plan on how facility will ensure that all exits are being monitor for the safety of residents that are not allowed to leave facility unassisted. Facility to submit a written plan by August 19, 2021. The following documentation is required for a change of administrator: LIC 200 (original - must be mailed or delivered to the Regional Office) LIC 308 Designation of Facility responsibility (designation of who is the administrator) Administrator Certificate First Aid Certificate Administrator Resume LIC 500 Personnel Report LIC 610 Emergency Disaster Plan for Residential Care Facilities for the Elderly LIC 501 Personnel Record LIC 503 Health Screening Report - personnel (keep on facility staff file to be reviewed) TB test that shows "negative" (keep on facility staff file to be reviewed) Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations) No deficiencies cited during today’s visit.the state’s words, verbatim · CDSS document, Aug 12, 2021