El Rio Memory Care Community

On 12/26/23 at approximately 12pm, Licensing Program Analyst Maja Jensen arrived at facility unannounced to continue an investigation in to the above listed allegations. LPA Jensen met with Executive Director Kent Mulkey and explained the purpose of today's visit. During the course of the investigation, LPA Jensen conducted interviews, met with residents and inspected resident rooms. Staff did not ensure a resident's grooming needs were met: LPA Jensen interviewed 8 of 8 staff present on this date. 8 of 8 staff gave consistent accounts of facility procedures for resident grooming which aligned with the admission agreement and regulation. LPA Jensen also interacted with residents during the course of 2 site visits and observed all residents to be adequately groomed therefore the allegation of Staff did not ensure a resident's grooming needs were met is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened, the preponderance of evidence does nRead the full finding— CDSS inspection report, December 26, 2023 · control 27-AS-20231011111327

On 12/26/23 at approximately 10am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue an investigation in to the above listed allegation. LPA Jensen met with Executive Director Kent Mulkey and explained the purpose of today's visit. During the course of the investigation LPA Jensen reviewed the resident file for Resident 1 (R1) and the admission agreement for R1. LPA Jensen also interviewed the Executive Director and the Director of Resident Services. The admission agreement specifies services that are included in the monthly rate as follows: -24 hour supervision -Laundry, room cleaning -Meals -Activities UnfoundedRead the full finding— CDSS inspection report, December 26, 2023 · control 27-AS-20231026091826

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with director of resident services Caress Brown and explained the purpose of the visit. This investigation consisted of interviews and record review. LPA Moleski interviewed facility administrator Kent Mulkey, 13 staff members (S1-S13), five residents (R2-R6), and a hospice nurse. Nine of the staff members interviewed were direct care staff, medication technicians, and/or licensed vocational nurses (S4, S5, S6, S7, S9, S10, S11, S12, S13). [continued on 9099-C] UnsubstantiatedRead the full finding— CDSS inspection report, December 21, 2023 · control 27-AS-20230825145457

On 10/27/23, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver complaint investigation findings regarding the above allegations. LPA identified herself, the purpose of the visit and asked to speak with the Designated Facility Administrator. The LPA met with Kent Mulkey and a brief interview followed. Regarding: Facility has an outbreak of scabies: On 07/27/23 at 4:43 PM, Community Care Licensing (CCL) received a complaint regarding a possible scabies outbreak at El Rio Memory Care. On this same day, LPA Viarella received a phone call from Karan Bassi, the Director of Resident Services (DRS), letting the LPA know that they suspected they might have a resident with scabies. On 08/04/23, the Director sent an LIC 624 stating that they had 4 residents whom they suspected of having scabies, with the first 2 exhibiting symptoms on 07/27/23. On 8/21/23, Stephen Sarine, Regional Director of Operations sent a letter to CCL that acknowledged tRead the full finding— CDSS inspection report, October 27, 2023 · control 27-AS-20230727163804

Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to open an complaint for the above allegations. LPA was greeted by Executive Director and explained the reason for the visit. Resident services director was present as well. LPA Lewis gathered documentation. Facility made copies for LPA of the invoices from clark pest control. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. Exit interview conducted. Copy of report given. UnsubstantiatedRead the full finding— CDSS inspection report, October 12, 2023 · control 27-AS-20231006160848

Licensing Program Analyst (LPA), Jason Lund conducted an unannounced visit on 3/29/2023 to amend the complaint and met with Administrator Mary Keaton and explained the reason for the visit. LPA Lund met with Administrator Carlin Robertson and explained the purpose of today's visit.Licensing Program Analyst (LPA), Jason Lund conducted an unannounced visit at the facility to Facility failed to seek timely medical care for the Resident’s pressure wound- On November 9th, 2022, resident (R1) was observed to have a lump on the right buttock that was hard, raw, extremely red and warm to touch. A Medical Physician was notified, and medication was prescribed. On November 13, 2022 the lump ruptured got grey and was infected. R1 complained that the wound was hurting, wasn’t feeling well and felt cold. On November 14th, 2022, R1 ate a small amount of breakfast and did not feel well. R1 did not want to eat dinner and went to bed early. SubstantiatedRead the full finding— CDSS inspection report, March 14, 2023 · control 27-AS-20221122165627

On 2-14-23 at 12:55pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate the complaint allegation noted above. LPA met with Administrator Mary Keaton and explained the purpose of the visit. During this investigation, LPA conducted interviews with Resident1 (R1), R2, and R3. LPA also conducted interviews with Administrator, Staff1(S1), S2, and S3. Additionally, LPA conducted facility observation including common areas, resident rooms, dining areas, and activity areas as well as caregiver stations. Based on interviews and observations, it was determined that facility is currently following COVID-19 precautions. LPA observed all staff to be wearing masks, and promoting social distancing as necessary. Additionally, LPA observed hand washing stations, appropriate availability of hand sanitizers, availability of additional masks, gowns, and other personal protective equipment (PPE) located in facility's storage areas and other areas available for stafRead the full finding— CDSS inspection report, February 14, 2023 · control 27-AS-20230209081012

Licensing Program Analyst (LPA’S) Kesha Lewis and Albert Johnson conducted an unannounced facility visit on 11/03/2022 to deliver complaint investigation findings. LPA’S met with Administrator Mary Keaton and explained the purpose of today's visit. The purpose of the visit is to deliver complaint investigation findings from an incident reported to the department received on 08/22/2022. Based upon documentation reviewed LPA’s observed multiple unwitnessed falls documented on internal documentation 6/30/2022, 7/5/2022, 7/6/2022, 7/19/2022,7/20/2022,7/22/2022. Interviews conducted with administrator and director of resident services they conformed that they do not send incident reports for falls unless resident is sent out to emergency room. R1’s Physician’s report states the resident has a history of falls. Based on records reviews and interviews LPA’S found inconsistencies with facilities incident reports and the department having no record of reports for those dates. Therefore, the secRead the full finding— CDSS inspection report, November 3, 2022 · control 27-AS-20220822080756

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on a complaint investigation. LPA Hurt met with facility lead nurse Robin Mendez and explained the purpose of today's visit. Regarding the allegation facility staff are not properly trained to deal with resident. Based on interviews and records reviewed the staff are properly trained to deal with dementia residents. LPA reviewed facility training documents that reflects the facility staff is receiving the required dementia training needed to assist facility dementia residents. LPA interviewed six facility staff who stated they were given training upon hiring, and they are also given 12 hours training annually including shadowing, class work, and videos. LPA reviewed facility training documents to include quizzes given to facility staff throughout the year about dementia. The facility staff interviewed all explained different techniques used to re direct residents, keep residents busy,Read the full finding— CDSS inspection report, October 11, 2022 · control 27-AS-20220907164059

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility September 26, 2022 at 10:30 a.m. to deliver findings on the above allegations. LPA Hurt met with facility Administrator Mary Keaton and explained the purpose of the visit. Regarding the allegation Facility has bed bugs. Based on interviews and records reviewed the facility does not currently have any resident rooms with active bed bugs. The facility did previously have rooms with bed bugs beginning in March 2022. Administrator Mary Keaton provided records documenting the local exterminator has been to the facility several times to inspect, and spray or heat treat different rooms. Administrator Mary Keaton stated the local exterminator would come out same day to confirm if there was actually bed bugs. Administrator Mary Keaton stated as soon as the resident rooms were confirmed to have bed bugs the staff would remove the resident from the room along with all clothing, and bedding to wash in high heRead the full finding— CDSS inspection report, September 26, 2022 · control 27-AS-20220815142727

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility on September 3, 2021 to deliver complaint findings. LPA identified herself and discussed the purpose of the visit with Administrator Mary Keaton. This investigation consisted of interviews with facility Administrator, complainant, and resident. Also reviewing of the resident files and facility records, and legal documents related to this complaint. Regarding the allegation that staff denied resident from having visitors. Based on LPA's interview with Administrator, complainant, and resident (R1), review of medical files, admission agreement, residence care plan, and temporary restraining order. It was determined that all persons not mentioned in the restraining order were still allowed to visit, call and have contact with resident. Only those mentioned in order were denied access to resident. This agency has investigated the allegation noted above and have found that the facility never denied resiRead the full finding— CDSS inspection report, September 3, 2021 · control 27-AS-20210728145900