Belmont Village Sabre Springs

Allegation investigated: Lack of supervision resulted in resident elopements. Licensee did not ensure staff were adequately trained.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Mark Ranno. On 02/12/2026 it was alleged that lack of supervision resulted in three (3) resident elopements, and Licensee did not ensure staff were adequately trained to care for residents with Parkinson's Disease. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Staff informed that the specific incidents in question were not considered to be elopements due to the residents in question being able to leave the facility unassisted during the timeframe of the incidents. Resident two (R2) walked down a stairwell and exited to the sidewalk, and staff redirected them back to the facility. Staff informed that R2 utilized a Wander Guard bracelet which alerted caregivers when they approached a doorway. Staff stated that R2's needs were complex and the facility was in regular contact with R2's doctor and family to help them live safely in the facility. (Continued on LIC9099 p.2) Unsubstantiated (Continued from LIC9099 p.1) Due to R2's increase in behavior episodes and agitation, the facility paid for a 1-1 private caregiver for additional supervision of R2. Staff informed that the second concern of a potential elopement occurred with Residents 3 (R3) and Resident 4 (R4), who had just moved into the facility at the time of incident. Upon admission, both residents were assessed by their primary care physicians to be able to leave the facility unassisted. The residents were married and R4 maintained high functioning. Subsequent observations after the residents were admitted showed that both residents required moderate supervision checks with reminders. The facility upgraded their care plans accordingly and both residents consented to utilize Wander Guards for safety. Regarding staff competency in caring for Parkinson's residents, staff informed that the annual training that caregivers were required to take provided knowledge for how to meet the basic care needs for any type of resident. The facility additionally provided a specific Parkinson's Disease in-service training to staff on 12/15/2025 with a geriatric specialist. R4 was interviewed during an unannounced facility visit. R4 denied that the facility did not provide adequate supervision for residents and informed that the incident they and R3 were involved in was a miscommunication, as it had not been established that they were unable to leave the facility without staff supervision. R4 informed that staff cared for them well and that they felt safe at the facility. R3 was unable to be interviewed due to passing away. R1 and R2 were unable to be interviewed due to no longer living at the facility. Two Outside Sources (OS1, OS2) were interviewed regarding the allegation. OS1, a prominent Geriatric Specialist in the county, provided training to facility caregivers on 12/15/2025 regarding caring for residents with Parkinson's Disease. OS1 informed that they provided a 40-minute training with a 20-minute Q&A session at the facility and the staff were engaged and asked good questions. OS1 stated that the facility's training to staff for residents with Parkinson's Disease was better than most in the county, and OS1 regularly recommended the facility to people with some of the highest care needs among this population. OS1 additionally stated that depending on the level of severity of the condition, the RCFE training regulations for Dementia care covered similar care needs for residents with Parkinson's. OS1 stated that the facility's care model went above the requirements, as they provided a licensed medical professional on staff 24-hours per day and the facility's caregiver training was more extensive than other facilities. OS1 did not have concerns about staff training for Parkinson's residents or supervision at the facility. OS1 noted that care for this population was nuanced, and an additional aspect was helping families to have realistic expectations of RCFE care. LPA interviewed OS2, a representative from an outside advocacy agency familiar with the facility. OS2 did not express concerns regarding supervision at the facility or how the facility cared for residents with Parkinson's Disease. (Continued on LIC9099 p.3) (Continued from LIC9099 p.2) OS1 was familiar with a possible elopement that occurred years ago, but did not know the supervision level required for the resident in question, and was unable to confirm if it was a true elopement. OS2 was aware that the facility had been accused of an elopement, but did not have further information or specifics regarding the situation. Relevant records were reviewed regarding the allegation. In-service training records corroborated that the facility provided specific training to caregivers for Parkinson's residents with OS1 on 12/15/2025. Additional core training and onboarding training records for all caregiving staff included Demenia care, ADLs, community safety, elopement procedures/prevention, first aid, identifying risk, evacuation chairs, resident rights, pendant call system, skin management, stages of Alzheimer's Disease, incontinence care, transfer assistance, and lift devices. LPA reviewed relevant records for the residents in question, including medical assessments, facility assessments, Needs and Services Plans, and care notes. The records corroborated staff statements regarding the situations that were presumed to be elopements. The records showed that each resident's initial assessment, upon admission, was aligned with the respective resident's assessment from their primary care physicians. The records additionally showed that the facility monitored each residents' condition and updated their plans of care according to their changing needs. Records showed that R2's responsible person was resistant to increasing the recommended services for R2's care plan, which increased R2's incidents of falling and attempts to exit the facility unassisted. Records showed that the facility updated R2's physician report regarding changes in behavior and requested a reassessment when R2 left the facility unsafely during an episode of agitation/disorientation. The facility paid for a personal 1-1 caregiver to provide increased supervision for R2. Staffing records showed that the facility scheduled 4-5 caregivers for each night shift in the Assisted Living section of the facility, in addition to a 24-hour nurse and Med Tech. The records showed that the staffing levels matched the acuity levels of the residents for that time of day. During an unannounced facility visit, LPA directly observed 3 staff walking with Circle of Friends residents, the program that provides higher supervision for residents with mild cognitive impairments who do not yet meet the level of need for the memory care unit. One staff was facilitating the group and two other staff were on the periphery monitoring the group of residents. One male resident became agitated/disoriented and began arguing with the facilitator and was assisted back to their room by one of the caregivers. Facility census during this time showed that there 16 residents in the Circle of Friends program. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Mark Ranno, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 21, 2026 · control 08-AS-20260212105806

Allegation investigated: Staff neglect resulted in serious bodily injury.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Mark Ranno. On 01/07/2026 it was alleged that staff neglect resulted in serious injury for Resident 1 (R1). The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Interviews and facility documentation showed that R1 resided in the Memory Care unit and was no longer independent with mobility due to physical decline. R1 required a Hoyer Lift supported by two staff members for all transfers. On 12/31/2025, while in the care of Staff 1 (S1), R1 fell during a Hoyer Lift transfer, suffering facial and knee fractures. Relevant caregivers and management staff were interviewed regarding the allegation. (Continued on LIC9099 p.2) Substantiated (Continued from LIC9099 p.1) Staff consistently stated that facility protocol strictly required two staff members to operate a Hoyer Lift safely. Facility management confirmed that caregivers received annual Hoyer Lift training, including S1. All interviewed personnel with knowledge of the incident corroborated that S1 neglected to seek the required assistance from a second caregiver for the transfer in question. Management informed that S1 was immediately suspended after the incident and subsequently terminated. S1 was interviewed regarding the allegation and admitted to the violation, stating they mistakenly attempted to transfer R1 alone. S1 additionally admitted to previously transferring residents without second-caregiver assistance because S1 perceived that their coworkers were too busy or unwilling to help. During the incident in question, S1 informed that one of the sling straps or loops failed to attach or secure properly to the Hoyer lift, resulting in the accidental fall. An outside source (OS1) responsible for R1’s care decisions informed that R1 had previously lost mobility in both legs and one arm, having minimal movement in the remaining arm. OS1 informed that upon speaking with facility staff after the incident, they were informed that the fall occurred due to a staff member conducting a Hoyer Lift transfer by themselves, which was contrary to facility policy. OS1 noted that the facility staff immediately initiated emergency medical services for R1 and were forthcoming regarding the incident. Facility records relevant to the allegation were reviewed. R1's Medical Assessment, dated 09/25/2025, stated that R1 suffered from a major neurocognitive impairment, motor impairment/paralysis, was not able to communicate needs or follow instruction, suffered from disorientation and lack of hazard awareness, and required full assistance with care needs. R1's Care Plan indicated that they required two-person assistance for transfers. The facility's Safe Transfer Policy indicated that residents requiring two-person assists must have two staff members present for transfers. Personnel records confirmed that S1 was terminated for transferring a resident without the assistance of a second staff member, which did not comply with safety procedures per company policy. Medical records revealed that R1 sustained facial and knee fractures as a result of the fall. (Continued on LIC9099 p.3) (Continued from LIC9099 p.2) Video evidence of the incident was reviewed during the investigation. The footage showed that S1 entered R1's room, electronically elevated R1's bed, dressed R1, repositioned R1 to place the sling underneath them, and transferred R1 using the Hoyer Lift. After this, the footage additionally showed that R1 fell face forward, S1 checked on R1 and immediately exited the room to seek assistance. The footage later showed paramedics entering R1's room to provide transport. Based on the comprehensive evidence obtained from staff interviews, camera footage, and the caregiver's own admission, it is proven that S1’s failure to practice mandatory safety precautions directly resulted in R1 sustaining facial and knee fractures. The preponderance of evidence has been met, therefore, the allegation of neglect resulting in serious bodily injury is substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Mark Ranno, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 21, 2026 · control 08-AS-20260107145531

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Aug 21, 2026

87411(a) Personnel Requirements: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met, as evidenced by: Licensee did not ensure that staff completed necessary services with competence (Hoyer Lift) in 1 of 49 residents. This posed an immediate safety risk for residents in care.the state’s words, verbatim · CDSS document, Aug 21, 2026

Plan of correction: Licensee agreed to ensure staff maintain annual Hoyer Lift training. Quarterly verification audits will be conducted for 10% of Hoyer lifts to confirm the transfer was conducted per procedure. Updated procedures to be submitted to LPA by POC due date.

Allegation investigated: Resident sustained multiple bruises due to staff neglect.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Mark Ranno. On 02/21/2024 it was alleged that Resident 1 (R1) sustained multiple bruises due to staff neglect. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, outside sources, and records review. Relevant staff were interviewed regarding the allegation. One staff interview was unsuccessful after multiple attempts. Staff interviews revealed that R1 was ambulatory with the assistance of a walker, and suffered from vision issues that affected their ability to ambulate without running into objects. Staff interviews additionally revealed that R1 was a memory care resident and tended to wander at night, forgetting to use their walker. This caused R1 to walk into furniture and other objects due to skewed vision. (Continued on LIC9099 p.2) Substantiated (Continued from LIC9099 p.1) Staff interviews further revealed that staff were unaware of the approximate twenty-five (25) red/purple marks on R1's arms and hands due to R1 typically wearing long sleeves covering their arms. Staff interviews revealed a gap in time of approximately two (2) months where written care notes were not documented for R1. Review of facility care notes for R1 showed a break in documentation from 12/14/2023 to 02/13/2024 where changes in R1's condition were not documented. On 02/14/2024 the documentation resumed, noting bilateral marks observed on R1's upper extremities. The documentation did not speak to any changes of behavior for R1 that precipitated the marks, what may have caused the marks, action taken by the facility to assist R1 with medical care for the marks, or notification to R1's primary care physician regarding the marks. The investigation did not produce consistent shower log documentation to show that the marks on R1 had been observed by staff. R1's Care Plan dated 12/10/2023, during the timeframe of concern, reflected that R1 was a fall risk due to vision impairment and required the use of their walker as a mobility aid. The Care Plan further noted that R1 required escorts to and from activities and the dining room daily. Pertaining to skin issues, the Care Plan listed, "Excessive Dryness" only as a skin condition. The Care Plan did not account for staff's knowledge of R1 being prone to bumping into objects or care to be provided to mitigate this. Records were not found to show that the facility communicated the marks on R1's arms and hands to their primary care doctor, or that staff attempted to evaluate the condition. No documentation was found to show that R1 was receiving Hospice services during the timeframe of concern. An interview was conducted with an outside source familiar with R1’s care and needs. Regarding the marks in question, the outside source stated they themselves determined the condition of the marks and they did not have R1 evaluated by a physician because the outside source had a medical background. The outside source informed that R1 had exhibited violent and aggressive behaviors with them, pushing and hitting the outside source, as well as practitioners during routine appointments. The outside source expressed concern that R1 was being physically abused at the facility, however no evidence provided confirmed that the claim was valid. Photos of R1's arms and hands during the timeframe of concern showed approximately twenty-five (25) dime and quarter-sized round marks along both of R1's upper extremities. The marks were shown to be purple, red, and brown in color. (Continued on LIC9099 p.3) (Continued from LIC9099 p.2 The staff failed to report R1’s bruises, and no action was taken by management to determine if R1 would benefit from additional services to meet their needs and avoid further injury. Management completed three resident assessments and service plans dated 12/10/23, 03/26/24, and 05/03/24 to determine the level of care R1 may require. Administration completed the assessments in which R1 continued to be evaluated between level one and level two care plans. The care plan indicated that R1 required staff to assist them walking to meals and activities as well as other basic daily tasks. Due to the lack of information provided by facility administration and staff regarding the bruises on R1, this indicated a lack of care and supervision. The facility administration failed to recognize the change in condition for R1 and did not initiate an overall medical assessment to ensure their safety and well-being. Therefore, the allegation of Neglect/Lack of Care and Supervision of resident R1, who sustained egregious bruising that went unnoticed and undocumented by staff, provides enough information to support the allegation. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and is therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Mark Ranno, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 21, 2026 · control 08-AS-20240221125035

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(A)(4) · Plan of correction due date: Aug 21, 2026

87468.2(A)(4) In addition to the rights listed in Section 87468.1... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs. Based on interviews and records review, the Licensee did not provide care, supervision, and services that met the individual needs of R1. This posed a potential health risk to 1 of 149 persons in care.the state’s words, verbatim · CDSS document, Aug 21, 2026

Plan of correction: Licensee amended their Plan of Operations pertaining to Observation, Evaluation of Residents, Annual Training, Monitoring Resident Emergency Alert Calls, Reporting Requirements, and Documentation. Licensee agreed to audit a percentage of resident and staff files quarterly to ensure resident evaluations/assessments and staff training are completed. Proof of correction was submitted to the Department. This satisfies the Plan of Corrections.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director Mark Ranno to discuss the purpose of the visit. Today's visit is in response to the facility's request to add a second delayed-egress door to the second floor of the building to expand the memory care unit. LPA conducted a tour of the facility and evaluated the area against the updated approved fire clearance granting the egress door. The information aligned with LPA's visual inspection. No deficiencies were cited or observed on this date. An exit interview was conducted with Executive Director Mark Ranno, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 21, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Amy Rodgers and Patrice Bazemore conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by and discussed the purpose of the visit to Executive Director (ED) Mark Ranno. The facility's license shows a maximum capacity of 184 non-ambulatory residents, ages 60 and above, it is approved for 32 bedridden and 23 in hospice waiver. Facility is equipped with delayed egress and secured perimeter. LPAs and ED toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required. The facility has a pool that was locked and inaccessible to residents. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed staff and clients, and reviewed facility records. The files reviewed by LPAs contained required documents. Confidential records were stored in locked areas. (continued on LIC809C) (continued from LIC809) During today visit LPA's observed a medication cart in the hall in the proposed memory care area of the facility. The lock on the medication cart was engaged. However, LPA checked drawers and 2nd drawer down was not locked and contained 4 bottles of pills with a residents name on them. During interviews with Staff #1 they explained the drawer broke that morning. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 809D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Interim ED Mark Ranno, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 6, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director Mark Ranno to discuss the purpose of the visit. Today's visit is in response to the self reported fall of Resident 1 (R1), who suffered a fall on 06/01/2026. R1 fell and suffered a hematoma to the left upper eyebrow area while being assisted by a caregiver. The incident report states that the resident lost balance and fell. R1 was assessed for injuries by the facility nurse and was sent out to the hospital due to evidence of hitting their head. R1's responsible person and doctor were notified. Upon discharge from the hospital, R1's scans were clear and they returned to the facility with no new orders. LPA collected facility records pertaining to the incident and interviewed R1. The staff members involved during the incident were not present at the facility during the visit. R1 partially recalled the incident and informed that it was not the fault of the caregiver. LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Executive Director Mark Ranno, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jul 10, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director Tracy Knepple, to discuss the purpose of the visit. Today's visit is in response to the self report regarding an emergency water shut off on 02/12/2026 due to a pipe leak. The investigation showed that the Maintenance Director observed a small pipe leak in the Memory Care building and initiated emergency maintenance the same day with a facility contractor. The memory care unit was informed that the hot water would be turned off from 7:00pm to 10:00pm and preparations were made not to shower residents during that time due to having cold water only. During the repairs the contractor observed an additional issue, resulting in a larger portion of hot water needing to be turned off suddenly. Due to the unexpected problem, it was not possible for the facility to provide timely notice to residents without significant consequences to the facility plant and increased resident safety risk. No residents were harmed during the incident. LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date. The investigation showed that the facility responded to an emergent situation and took immediate measures to prevent risk to residents. An exit interview was conducted with Tracy Knepple, Executive Director, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Feb 18, 2026

Allegation investigated: Staff did not assist resident in a timely manner. Staff were not properly trained in emergency procedures.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Tracy Knepple. On 01/22/2026, it was alleged that staff did not assist Resident 1 (R1) in a timely manner, and staff were not properly trained in emergency procedures. The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff, residents, and records review. Staff interviews revealed that staff followed the official facility procedures, in order, for a false alarm by locating the alarm source, deactivating the alarm, deactivating the strobe light, cancelling the fire department, notifying management, responding to resident pendant calls, and giving the "all clear". Staff interviews additionally revealed that the response time for the resident in question during the false alarm was reasonable at 22 minutes, during which time all residents had pushed their pendants as well. Staff interviews revealed that all staff were trained for fire emergencies upon hire, and annually and monthly thereafter. (Continued on LIC9099 p.2) Unsubstantiated (Continued on LIC9099 p.2) Staff were also spot-trained on a random basis regarding fire emergencies and what to do. Staff provided information regarding the process during emergency procedures, which was consistent with facility records and procedures regarding emergencies. Resident 1 (R1) was interviewed during an unannounced facility visit. R1 stated that their main concern was what felt like a delay in communication regarding the "all clear", after staff confirmed the incident to be a false alarm. R1 acknowledged that during the time of the incident, staff were assisting all residents in the community, including residents with higher care needs. R1 informed they appreciated their feedback to the facility being taken seriously, and R1 has been involved in updating the resident-facing communication regarding what to do in emergencies. Records review revealed consistent emergency training conducted by staff annually and monthly, which corroborated staff statements. R1's pendant log showed that R1 received assistance from staff 22 minutes and 30 seconds after pushing their pendant, which was during the false alarm. During an unannounced facility visit LPA directly observed the location where the fire alarm was pulled, the alarm stations, fire extinguishers, and fire alarms throughout the building. The observations made by LPA were consistent with staff interviews, resident interview, and records reviewed. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Tracy Knepple, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 08-AS-20260122124442

Type of visit: Case Management - Other

An Office Meeting was conducted to review the Stipulation and Waiver and Order adopted on September 18, 2025. Those present for the Department of Social Services (Department) were: Jerry Romero, Regional Manager Sabel Martinez, Licensing Program Manager Present for Belmont Village Sabre Springs were: Douglas Armstong, Senior Vice President of Regulatory Affairs Tracy Knepple, Executive Director Regional Manager reviewed and discussed the agreed upon and Adopted Decision and Order dated September 18, 2025. Douglas Armstrong and Tracy Knepple understands the following is required for compliance with the Order. An exit interview was conducted with Douglas Armstrong and Tracy Knepple to whom copies of this report and Licensee Rights were provided. A new license will be issued with the probationary status indicated. A signature from Tracy Knepple on this form acknowledges receipt of the report and rights.the state’s words, verbatim · CDSS document, Oct 20, 2025

Allegation investigated: Staff did not treat resident(s) with respect. Staff left medication(s) in resident's room. Resident left facility unassisted.

Licensing Program Analysts (LPAs) Nacole Patterson, Ramin Hashemi, and Janet Ngallo conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above complaint allegations. LPAs introduced themselves and disclosed the purpose of the visit to Executive Director Tracy Knepple. On 08/22/2025 it was alleged that staff did not treat resident(s) with respect, staff left medication(s) in a resident's room, and a resident left the facility unassisted. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "Staff did not treat resident(s) with respect", it was alleged that staff mocked Resident 1 (R1) and made them feel uncomfortable. Staff interviews did not corroborate the allegation, as no staff informed of observing or having knowledge of a staff member engaging with a resident in an undignified way. Staff members interviewed denied that a resident or family member informed them of being treated poorly by any caregiver. (Continued on LIC9099 p.2) Unsubstantiated (Continued from LIC9099 p.1) Resident interviews did not corroborate the allegation. Residents stated that staff treated them well and expressed no concerns. R1 was interviewed during the facility visit and stated that staff treated them well. R1 did not express concerns about staff treating them disrespectfully; R1 stated they were happy with the care they received and stated they would change nothing about the care provided at the facility. Outside source interviews did not corroborate the allegation. An outside advocacy agency familiar with the facility stated that they had no concerns regarding residents' being treated with dignity by staff. R1's Responsible Party informed that staff treated R1 very well and stated they had no concerns regarding staff treatment toward R1. No records were found to give evidence to this allegation. Staff records were absent of write-ups regarding staff treating a resident without respect. Care notes for R1 were absent of any situations regarding lack of respect/dignity by staff. LPAs directly observed resident care during the facility visit. LPAs observed staff assisting residents with programmed activities, in groups, and activities of daily living (ADLs). These observations include times when staff were unaware of the LPAs' presence. LPAs did not observe any staff member engage with a resident in a disrespectful way. Regarding the allegation, "Staff left medication(s) in resident's room", it was alleged that unsecured medication was left in Resident 2 (R2)'s room. Staff interviews did not corroborate the allegation, as staff denied seeing any unsecured medications in a resident room who was unable to administer their own medications. Resident interviews did not corroborate this allegation. Five (5) residents were interviewed regarding medications, 3 of whom informed they administered their own medications. One resident only received pro re nata (PRN) "as-needed" pain medications and informed that there were no issues. R2 refused interview, however, LPAs briefly observed R2's room and noted that no loose medications were observed in the room. Two outside sources familiar with the facility were interviewed regarding medication administration. The outside sources did not express concerns about medication administration and had not been made aware of any medication issues. (Continued on LIC9099 p.3) (Continued from LIC9099 p.2) No records were found to give evidence to this allegation. Staff records were absent of write-ups regarding medications being left in a resident's room. R2's assessments revealed that R2 did not administer their own medications. Care notes for R2 during the timeframe of complaint were absent of any incidents where medications were found in R2's room. Notations existed in R2's Care Notes regarding missed medications, however those situations were due to R2's refusals of the medication pass. Regarding the allegation, "Resident left facility unassisted", it was alleged that Resident 3 (R3) left the facility without required staff supervision. Staff involved in the incident informed that R3 possibly experienced an episode of delusion during the incident due to observing paranoid behaviors outside of R1's baseline. Staff interviews additionally revealed that R1 was able to leave the facility unassisted, however, due to staff's concerns regarding R1's mental state, staff accompanied R1 as they left the facility, and additional staff responded to their location as well as R3's responsible party and paramedics. R3 was unable to be interviewed due to being out of the facility during the facility visit. An outside advocacy agency familiar with the facility did not have concerns about residents leaving unassisted and had not been made aware of any situations where a resident left the facility without required supervision. This outside source also did not have concerns about general resident supervision at the facility. Review of facility records revealed that the incident was reported as required. R3's Physician's Report did not indicate that R3 was unable to leave the facility unassisted. The incident report details were consistent with staff interviews that R3 was accompanied by staff when they left the facility. Facility records additionally revealed that R3 was not noted to require wearing a Wander Guard. R3's charting notes were consistent with staff statements regarding R3's episode of delusion, wanting to leave the facility, and staff accompanying them outside. R3's Charting Notes also showed that R3 was assisted in the community by staff. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Tracy Knepple, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 08-AS-20250822131655

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Nacole Patterson and Jose De La Cruz conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by and discussed the purpose of the visit to Executive Director (ED) Tracy Knepple. The facility's license shows a maximum capacity of 184 non-ambulatory residents, ages 60 and above, it is approved for 32 bedridden and 23 in hospice waiver. Facility is equipped with delayed egress and secured perimeter. During today’s inspection there were 149 residents in care. LPAs and ED toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. The facility has a pool that was locked and inaccessible to residents. Per ED, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed staff and clients, and reviewed facility records. The files reviewed by LPAs contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with ED to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 7, 2025

Allegation investigated: Staff forcefully administered medication to resident in care

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegation. LPA met with Executive Director, Tracy Knepple. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged that staff forcefully administered medication to a resident in care. It was reported a nurse/area manager forcefully administered an insulin injection to Resident #1 on 06/10/25. R1 receives medication management from the facility staff. Staff interviewed reported R1 was known for refusing medications but not their insulin. A review of R1’s Medication Administration Records (MARs) for June 2025 indicated R1 refused medications and or insulin on 06/01/25; 06/02/25; 06/08/25; and 06/10/25. Further staff interviews showed that R1 had agitation at times and will refuse medications. Facility’s Progress Notes dated 06/10/25 indicated R1 was agitated and did not want to take their medications. Continued on an LIC 9099C. Substantiated It also stated that R1 continued to verbalize “don’t touch me, I don’t want anything done” and that the nurse was able to provide medications at noon. However, the MARs were documented on 06/10/25 that the medication/insulin was administered in the morning, not noon, and signed off by the nurse. The interview conducted with the nurse/area manager confirmed R1 didn’t want to take anything, but the nurse/area manager stated they were able to have a discussion to coax R1 to take it, then R1 agreed. The nurse/area manager explained they administered two injections quickly to R1 but not forcefully. Staff interviews revealed that R1 said they didn’t want their medications. The nurse/area manager was witnessed pulling R1’s sleeve up and administering the insulin, while R1 was stating they didn’t want it. It was reported R1 left crying. R1 was not interviewed due to a Major Neurocognitive Disorder and no longer residing at the facility. On 06/12/25, R1 moved out of the facility. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Aug 5, 2025 · control 08-AS-20250612101952

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Sep 2, 2025

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To receive or reject medical care or other services. This requirement is not met as evidenced by: Based on interviews and records, the licensee did not allow 1 out of 149 [R1] residents to refuse their medications/insulin, which posed a potential safety and personal risk to residents in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Executive Director agreed to have all staff that administer medications including the regional nurse/area director of clinical services attend personal rights training by an outside vendor and submit proof of training by POC due date.

Allegation investigated: Staff are falsifying documentation

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above-mentioned allegation. LPA met with Executive Director, Tracy Knepple. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged staff are falsifying documentation. It was reported that multiple medication technicians (med tech) are falsely documenting the Medication Administration Record (MARs) as the medications were administered when they were not. An outside source reported it was discovered the medications were present after the time they were documented as administered. On 05/30/25, LPA reviewed multiple medications and did not observe leftover medications or medications not administered. The outside source indicated multiple residents did not receive their medications due to their MARs being falsified as given. Those residents were interviewed and confirmed they were provided with medications as prescribed. Continued on an LIC 9099C. Unsubstantiated A review of the MARs for the residents identified, were accurate and reflected the medications were dispensed as prescribed. Med tech’s interviewed, confirmed medications were given as prescribed. The Nurse Liaison’s interview indicated there are sometimes glitches in their electronic MARs system. However medications are given as prescribed, and they are able to document the medications on paper MARs. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Aug 5, 2025 · control 08-AS-20250522103519

Allegation investigated: Neglect resulting in resident sustaining pressure injury Neglect resulting in resident sustaining an infection in the mouth Staff do not seek medical attention to residents in a timely manner Residents are not treated with dignity Facility does not provide activities for residents in care Facility has rodents Facility is in disrepair

Licensing Program Analyst (LPA) Natasha Persaud contacted the facility via telephone to commence a complaint investigation regarding the above-mentioned allegations. LPA spoke with Executive Director, Tracy Knepple and discussed the elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside agency and LPA observations. It was reported to CCL neglect resulting in resident sustaining pressure injuries, neglect resulting in resident sustaining an infection in mouth, staff do not seek medical attention in a timely manner, residents are not treated with dignity, facility does not provide activities to residents in care, facility has rodents and facility is in disrepair. Continued on an LIC 9099C. Unsubstantiated Regarding the allegation, neglect resulting in resident sustaining pressure injuries, it was reported that Resident (R1) sustained pressure injuries as a result of the facilities’ neglect. A records review revealed a doctor’s note dated 5/22/2023 stating that R1 had stage 2 pressure injuries, and it was ordered that R1 was to receive wound care twice a week and be repositioned every two hours. Records review showed that hospice nurses visited R1 and provided wound care. Interview with outside source (OS1) revealed that R1 was provided wound care by hospice nurse and was repositioned by private caregiver. Interviews with facility staff revealed that staff reposition residents who are at risk of pressure injuries every two hours and reported no concerns for resident neglect. Regarding the allegation, neglect resulting in resident sustaining an infection in mouth, it was reported that R2 sustained a rash in the mouth due to facility neglect. Records review revealed that R2 was prescribed medication Nystatin to treat infection in mouth and was seen by a Home Health agency. Records review show that there was a delay in getting the signed doctor’s order for the Nystatin due to the doctor’s office not sending over the order. Records review showed the facility advocating for the resident by calling the doctor’s office and requesting to follow up on doctor’s order. Interviews with facility staff revealed that staff had no concern for facility neglecting residents and reported that all residents are cared for. Interviews with residents revealed no concerns. Interview with outside source (OS2) revealed that staff reported the infection in R2’s mouth immediately and medical attention was sought out. Regarding the allegation, staff did not seek medical attention in a timely manner, it was reported that residents have made complaints such as being in pain and staff do nothing. Interviews with facility staff revealed no concern for residents not receiving timely medical attention. Interviews with residents revealed no concern for delay in seeking medical attention. Interview with outside source (OS2) revealed no concern for residents not receiving timely medical attention. Regarding the allegation, residents are not treated with dignity, it was reported that residents are not allowed to go outside. LPA conducted a walk through of facility and observed several doors that lead to outside area to be unlocked and accessible to residents. Interviews with staff revealed that residents are allowed to go outside, and facility has ample outside area for residents to utilize. Interviews with residents revealed that there is an outside area for residents to go to that is always available. Interview with outside source (OS1) revealed that facility has an outside area, and residents are able to go to outside area. Continued on an LIC 9099C. Regarding the allegation, facility does not provide activities to residents in care, it was reported that residents are not provided any activities. LPA observations revealed that an activities calendar is posted in multiple areas of the facility, including elevators, entrance of memory care and hallways. LPA observed morning exercise activity being conducted in memory care unit. Interviews with residents revealed that there are activities every day. Interviews with facility staff revealed that activities are offered daily and are changed every month. Regarding the allegation, facility has rodents, it was reported that rodents have been found in the kitchen. LPA toured facility kitchen and did not observe any rodents or any indication that facility has rodents. Interviews with facility staff revealed no concern for rodents at the facility. Interviews with residents revealed no concern for rodents. Regarding the allegation, facility is in disrepair, it was reported that the facility ceiling is leaky and moldy, there is owl feces leaking through the walls of the Casa Blanca Room, and resident 3 (R3)’s wall paint is chipping and in disrepair. LPA did not observe any leaky or molding areas in facility ceiling. LPA observed Casa Blanca Room (on bottom floor in memory care) and did not observe any owl feces leaking through walls. LPA observed R3’s room and observed wall paint to be intact and not chipping or peeling. LPA did not observe any concern for the building and grounds while conducting a walk through. Interviews with facility staff revealed no concerns for facility being in disrepair. Interviews with residents revealed no concern for building and grounds or cleanliness of facility. Interview with outside sources (OS1 & OS2) both revealed no concerns for building and grounds. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met, and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple via email. [See LIC 811 Confidential Names List to identify Resident #1 and #2]the state’s words, verbatim · CDSS document, May 14, 2025 · control 08-AS-20240327115517

Allegation investigated: Facility staff did not respond timely to resident's calls for assistance

Licensing Program Analyst (LPA), Natasha Persaud conducted a visit to conclude the complaint investigation regarding the above-mentioned allegation. LPA met with Executive Director, Tracy Knepple. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff and outside sources. It was alleged facility staff did not respond timely to Resident #1’s (R1) calls for assistance. R1’s Physician Report dated February 13, 2024, indicated R1 had a Major Neurocognitive Disorder, bedridden status, and receiving hospice services. The report also reflected R1 required assistance with bathing, dressing/grooming, toileting, feeding, and medication management. R1’s Service Plan dated May 3, 2024, indicated R1 required assistance with bathing, dressing/grooming, toileting, feeding, two person transfers, and medication management. Facility’s PAL (Personal Assistance Liaison) Approach Chart and Service Plan dated June 2024 indicated R1 required assistance with toileting; feeding; medications; dressing; transfer assistance by two staff members/hoyer lift required. R1 resided in the memory care at the facility. Continued on an LIC 9099C. Substantiated Per the Executive Director (ED), the residents in memory care do not have call pendants as they do not have the cognitive ability to push the call button. All resident rooms have a pull cord for assistance. Once the pull cord is activated, it alerts the staff’s pager. ED added R1 had a twenty-four (24) hour private companion, no reason for delay in care. R1 was not mobile, no safety risk if companion left R1’s room to go get additional support from facility staff. Interviews with private companions revealed they would pull the pull cord and have to wait 30-60 minutes for staff to respond. A review of daily notes for March 2024 completed by the private companion indicated delay in care for R1. The daily notes also stated the private companion would pull the pull cord or have to go into the hall looking for facility staff to change and reposition R1. R1’s Call Light History log for February 2024, reflected multiple response times of six (6) hours; five (5) hours; four (4) hours; two (2) hours, and one (1) hour. R1’s Call Light History log for March 2024, reflected multiple response times of five (5) hours; six (6) hours; and four (4) hours. R1’s Call Light History log for April 2024, reflected multiple response times of over two (2) hours; R1’s Call Light History log for May and June 2024, reflected response times over forty-five (45) minutes. R1’s private companion reported delay in care for R1 during those reported times frames. Staff interviews revealed they responded timely. Staff also stated R1 was a two (2) person assist and when R1 required assistance the caregiver would go to R1’s room and call for another caregiver to assist. Some caregiver interviews revealed once they arrived to R1’s room, R1’s private companion would assist with brief change and repositioning of R1. R1’s family obtained a private companion twenty-four (24) hours per day, in addition to the facility’s caregivers. The private companions were hired to provide companionship, not direct care. A review of private companion’s daily notes for March 2024 showed there were some occasions where the private companion pulled the pull cord for assistance and staff did not arrive to assist. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights. A civil penalty was assessed for a repeat violation within a 12 month period. [See LIC 811 Confidential Names List to identify Resident #1] The nurse reported R1 was complaining of head pain as well as leg pain. The nurse’s interview revealed it was facility policy to send a resident out for evaluation when they hit their head. Therefore, the facility contacted 911. The nurse also reported R1’s responsible party was upset that R1 was sent out for medical evaluation before calling R1’s responsible party and the nurse explained it was their policy. On February 3, 2024, R1 was transported to hospital and diagnosed with a fractured hip. R1 was recommended to go to a Skilled Nursing Facility (SNF) after being discharged from the hospital. The Director of Resident Care Services (DRCS) explained R1’s responsible party refused and didn’t want R1 going to a SNF due to a bad experience. The Executive Director (ED) advised R1’s family that R1 could return back to the facility if R1 was placed on hospice and if they hired a 24/7 caregiver to take care of R1, which R1’s responsible party agreed. On February 11, 2024, R1 was admitted back to the facility and placed on hospice care with around the clock care giving services provided by facility staff and an outside agency. The facility staff acted appropriately with the fall and as soon as head trauma was determined, 911 was immediately called with no hesitation. It was also alleged neglect resulting in Stage three (3) pressure injury for R1. On February 3, 2024, R1 fell at the facility and was transported to the hospital. On February 11, 2024, R1 returned to the facility, and it was reported R1 sustained a pressure injury on their coccyx that was covered with a dressing. The facility’s DRCS stated after R1’s fall they became bedridden and unable to walk on their own, and R1’s hospice agency was required to provide wound care one (1) to two (2) times a week. DRCS explained R1’s pressure injury would shift between a Stage one (1) and a Stage two (2) constantly. DRCS also stated R1’s pressure injury was right on their backside which didn’t help with healing because every time R1 had a bowel movement it would get soiled. DRCS’ interview revealed the facility’s policy allows residents to remain in the facility with wound/pressure injuries if the wound is lower than a Stage one (1) or Stage two (2). However, once the wound progresses to a Stage three (3), that is considered a prohibited health condition, and the resident must be sent out to a SNF until the wound/pressure injury is healed. The Wound Specialist’s interview revealed it was hard to get R1 to cooperate at times and R1 didn’t like assistance. The Wound Specialist also confirmed R1’s wound started out as a Stage two (2) and progressively got worse because it was one of those challenging areas and it was hard to keep R1 off their back. On July 3, 2024, the hospice agency advised that R1’s pressure injury progressed to a Stage three (3). Continued on an LIC 9099C. On July 4, 2024, the ED, DRCS and Wound Specialist all met to discuss R1’s pressure injury and the possibility of it progressing to a worse stage quickly if R1 isn’t seen by medical professionals. R1’s pressure injury wound had eschar (a dry, crusty layer of dead tissue that forms on the surface of a wound, according to the Mayo Clinic) and redness around it, a non-emergency transport was scheduled to take R1 to the hospital for further evaluation. ED’s interview revealed R1’s responsible party was not pleased with R1 being sent to the hospital. The DRCS reported they discovered R1’s pressure injury got aggressive while R1 was at the hospital, and R1 required a wound vac. After R1’s hospitalization, they did not return to the facility. The Wound Specialist commented that sending R1 to the hospital for evaluation was the right thing to do because if R1 would have remained at the facility, the pressure injury would have gotten worse. The facility was in communication with the hospice agency and followed their direction by seeking professional assistance for R1’s medical care. The facility ensured R1 received required medical treatment for R1’s pressure injury. Lastly, it was also alleged facility staff did not follow R1’s admission agreement. It was reported R1’s responsible party was being over charged by paying for additional caregivers. Outside source interviews revealed R1’s responsible party was paying for hospice services, private companions 24 hours a day, and extra money for an additional facility staff to be available to assist the private companions, whenever they needed it. R1’s Admission Agreement dated July 30, 2021, indicated a basic rate with no additional support. The facility issued an Amendment to Resident Service Agreement for Change in Residence dated February 21, 2023. The change reflected R1 required Enhanced Personal Care I with a charge of $1150, in addition to the basic rate. The Admission Agreement reflected Enhanced Personal Care I included hands on assistance with showering more than four times per week, transfer assistance by one (1) staff member and any service included in basic personal care. However, R1 was receiving showers/bathing from hospice agency staff. The ED’s interview revealed R1 was receiving Enhanced Personal Care II, which required a two (2) person assist but the documentation reflected Enhanced Personal Care I. The facility followed the Admission Agreement by providing notice to the resident/responsible party of the increase charge of $1150, which was signed by the responsible party, agreeing to the additional charge. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 08-AS-20240806141711

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 10, 2025

Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on record review, the licensee did not respond to 1 out of 155 [R1] residents’ requests for assistance in a timely manner. Some resident wait times were up to 6 hours for staff to respond to and restore pendants. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 10, 2025

Plan of correction: ED implemented a new policy regarding decreased response time. The facility purchased new staff communication equipment and provided training on the new policy and provided proof on 08/16/24. POC corrected. A civil penalty was assessed for a repeat violation within a 12 month period.

Allegation investigated: Medications not given as prescribed Licensee did not ensure resident medication records were accurate

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation. LPA met with Executive Director, Tracy Knepple. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged medications were not given as prescribed for Resident #1 (R1) and Resident # 2 (R2). It was reported R1 was not given the correct dose of morphine, R2 was provided medication patches that belonged to Resident # 3 (R3), and medications were missing. R1 was receiving hospice services. Staff interviews revealed hospice was changing the morphine orders from half tab to full tab and back to half tab, as frequent as three (3) times in one (1) week. Staff explained the medication orders went directly to the pharmacy contracted by the facility. Once the order was placed, it appeared in their medication administration system, ACCUflo. Staff followed the ACCUflo system to administer medications. Continued on an LIC 9099C. Substantiated The facility’s Controlled Drug Record for March 2025 indicated the morphine was given. However, the Medication Administration Record (MAR) does not match based on the doses and dates. R2 had prescribed patches as well as R3. R2 resided in the assisted living portion of the facility and R3 resided in the secured memory care unit. Staff interviews revealed as they were going to administer/apply the patch to R2, when they observed the already applied patch was incorrect. Staff stated the patch was different in size, so they checked the milligrams and noticed it was 9.6mg, instead of prescribed 4.6mg. Staff’s interviews confirmed the medication was not given as prescribed, as it was for another resident. Staff stated three residents within the facility had a prescription for patches and only R2 and R3 were prescribed the same medication name but different doses. LPA was unable to observe the patches, as the facility had them destroyed. It was also alleged licensee did not ensure resident medication records were accurate. R1’s morphine prescription was frequently changing doses from 1 full tab to 1 half tab and back and forth, within a short period of time. Due to the facility’s medication technician cutting a full tab into a half tab, documentation was required to account for the wasted half tab. The nurse’s interview confirmed when a medication is wasted or not given, it’s documented on the Medication Administration Record, not the Controlled Drug Record and destroyed using the drug buster. A review of R1’s Controlled Drug Record indicated on 03/09/25, a pill was wasted but didn’t reflect how much was wasted or why. Some staff interviews revealed they were not sure where to log the wasted pill. An email dated 03/26/25 from the facility’s Senior Vice President, Regulatory Affairs confirmed the staff failed to document the half pill destruction on the morphine log. The email also stated extensive mandatory training for all staff assisting with medication administration will be conducted. Med Tech interview confirmed they destroyed the wasted half pill but forgot to document it on the destruction record. The wasted pill was documented on the Control Drug Record, dated 03/09/25. However, none of the other wasted pills were documented on that record. According to the facility’s Morphine and MAR Audit log for March 1-10, 2025, there were six wasted pills, and they were not documented on the Controlled Drug Record. Per staff, wasted pills are documented on the Destruction Record, not the Controlled Drug Record, even though it was documented as wasted for 03/09/25. A review of R1’s MARs reflected multiple morphine prescriptions regarding full and half tab. It was unknown if pills that were wasted were considered missing, as the staff indicated medications not used are destroyed in the drug buster, which is a solution to destroy medication. Continued on an LIC 9099C. The Controlled Drug Record for 03/07/25 showed full tab of morphine was administered three (3) times; half tab was administered two (2) times. However, the MAR does not match the Controlled Drug Record. The MAR for 03/07/25 showed only four half tabs were dispensed that day. The MAR did not have an order to dispense full tab for 03/07/25. The MAR had an order of half tab every 6 hours that started on 03/05/25 and was discontinued on 03/08/25. The Controlled Drug Record for half tab dispensed on 03/07/25, indicated half tab every 4 hours. There was no order on the MAR for a full tab to dispense on 03/07/25, as the orders were probably pending with the frequent changes. It is unknown if R1 received correct doses due to the discrepancies between the MAR and the Controlled Drug Record. Nurses and Medication Technician’s confirmed the wasted pills are documented on the destruction record, not the Controlled Drug Record. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights. A civil penalty was assessed for a repeat violation within a 12 month period. [See LIC 811 Confidential Names List to identify Resident #1, #2, and #3] Medication Technician admitted to cutting the pill without the order and stated the nurse was aware. The nurse’s interview confirmed the medication technician was provided approval to cut the pill and the nurse witnessed the pill being cut. The facility was able to cut the pill to ensure the correct dose was being administered to R1. Director of Resident Care Services' interview revealed if the order is for half tab but they have full tab, they can cut it, because it’s according to medication dosing. As long as the correct medication is administered, it’s not a concern. Even though there wasn't an order on file to cut the pill, there was an order for a half pill dose. The pill was not cut in order to camouflage but to administer the correct dose. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 08-AS-20250312121604

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 10, 2025

Incidental Medical and Dental Care. A plan for incidental medical...be developed by each facility. The plan shall encourage routine medical...by compliance with the following: The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews, the licensee did not ensure medications were given as prescribed for 2 out of 152 [R1-R2] residents, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 10, 2025

Plan of correction: Executive Director (ED) was proactive and had staff attend medication training. ED submitted proof of training. POC corrected. A civil penalty was assessed for a repeat violation within a 12 month period.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Apr 10, 2025

Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure a complete MARs was maintained 1 out of 152 [R1] residents, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 10, 2025

Plan of correction: Executive Director (ED) was proactive and had staff attend medication training regarding medication documentation. ED submitted proof of training. POC corrected.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident visit. LPA met with Executive Director (ED), Tracy Knepple and discussed the purpose of the visit. The facility self reported an incident regarding Resident #1 (R1). On 03/23/25, R1 had an unwitnessed fall, injuring their right hip and middle finger. ED explained R1 was independent and managed their own medication. Approximately nine (9) months ago, R1 was no longer independent and required assistance with activities of daily living, but could transfer independently and used a walker for long distances. The facility acted appropriately with medical care and contacted 911. R1 was transported to the hospital and diagnosed with a hip fracture. R1's responsible party decided against surgery for the hip fracture. R1 returned to the facility and was already receiving hospice services for comfort care. ED stated the care plan was updated to follow physician orders. ED also stated they continued to monitor for change of condition in partnership with hospice. Per the ED, R1 qualified for hospice services based on a medical condition, unrelated to the fracture. On 03/28/25, R1 passed away at the facility with their family by their side. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Apr 10, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Juliana Barfield arrived on April 8, 2025 for an unannounced inspection to follow up on an incident investigation reported by the facility. LPA met with Tracy Knepple. On March 28, 2025, the Department concluded an incident investigation regarding a self-reported incident involving delayed medical care to resident (R1). The licensee was cited for California Code of Regulations (CCR) § 87465(g) Incidental Medical and Dental Care. At the time of the case management visit on March 28, 2025, the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the licensee did not immediately telephone 9-1-1 for R1, who had fallen, was expressing pain, and could not get out of bed due to experiencing extreme physical pain. Today, April 8, 2025 the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes a serious bodily injury to R1 in the amount of $10,000.00. Exit interview conducted. A copy of the report issued. Appeal rights provided to Tracy Knepple and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Apr 8, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced Case Management visit to conclude an incident investigation. LPA met with Memory Program Coordinator, Aiyana Martinez. On September 24, 2024, the Department received an Unusual Incident Report from the facility regarding an incident involving Resident #1 (R1). According to the facility's report, R1 sustained a fall on September 21, 2024, and a facility nurse assessed R1 and observed grimacing and a lack of movement on the left side of their body. The nurse recommended an evaluation by emergency services; however, both R1 and their responsible party declined and R1 was not treated by medical professionals. As a result, the Department opened an investigation into the delayed medical care of R1. A review of R1’s Physician’s Report, dated July 31, 2024, indicated a diagnosis of Major Neurocognitive Disorder (MND) and stated that R1 required assistance with bathing. The report also noted that while R1 could communicate their needs, they experienced a loss of intellectual function, including difficulty making decisions. A review of R1’s Assessment/Service Plan, dated September 3, 2024, indicated that R1 required assistance with bathing, dressing, grooming, and escort assistance while walking to meals and facility-planned activities. A review of R1’s facility records reflected that R1 had a fall on July 28, 2024, and complained of wrist pain. R1 was taken to the hospital by their responsible party and was advised to return for a cast once the swelling subsided. Further record review indicated that R1 fell again on July 29, 2024. Facility staff called 9-1-1, and R1 was transported to the hospital, where they were diagnosed with a hematoma on the back of their head. Additionally, on July 31, 2024, R1 self-reported increased pain in their left arm, prompting facility staff to call 9-1-1 for transport to the hospital for further evaluation. Continued on an LIC 809C. Facility records also reflected additional falls involving R1 on the following dates: August 2, 2024, when R1 complained of left arm pain but was only monitored; August 24, 2024, with no reported pain; and September 11, 2024, when R1 sustained a small cut on their forehead. Paramedics responded and provided care for the injury. On September 21, 2024, R1’s responsible party was assisting R1 with a shower in their room. When the responsible party heard a knock at the door and stepped away to answer it, R1 fell in the shower, landing on their left side. The person at the door was a caregiver who immediately responded to assist R1 and called the on-duty facility nurse. The nurse conducted a head-to-toe assessment and noted no visible injuries. R1 was able to move all extremities; however, they grimaced when reaching for the shower bar with their left hand. The nurse recommended that R1 be transported to the hospital for evaluation, but both R1 and their responsible party declined. The responsible party indicated they would take R1 to the hospital if their pain persisted. The facility placed R1 on “alert charting” to monitor them more frequently for pain or changes in condition. On September 26, 2024, the on-duty nurse became concerned when R1 did not want to get out of bed for breakfast or lunch. The nurse called R1’s responsible party to express concerns, stating they believed R1 might be experiencing pain from the fall on September 21, 2024, or possibly had a urinary tract infection. The nurse recommended R1 be transported to the hospital by ambulance, but R1’s responsible party stated they would take R1 themselves. They drove R1 to an urgent care, where R1 was diagnosed with non-operable rib fractures on the left side. As a result, R1’s responsible party transported R1 to the hospital for further care. The Executive Director (ED) stated in an interview that R1 had experienced an increase in unwitnessed falls in their room since August 2024, which they attributed to R1’s cognitive decline. The ED also stated that after each fall, R1 was assessed by a facility nurse, and on some occasions, the nurse recommended that R1 be transported to the hospital for evaluation. When 9-1-1 was called, R1’s responsible party would often arrive before the paramedics and sign an Against Medical Advice (AMA) refusal, declining hospital transport for R1. The Director of Resident Care Services (DRCS) confirmed in an interview that there were instances when the facility nurse recommended that R1 be sent to the hospital for evaluation, but R1’s responsible party refused medical care. Continued on an LIC 809C. The DRCS also stated that on September 21, 2024, after R1’s fall, the on-duty LVN assessed R1 and found no visible injuries. However, R1 complained of pain when stretching out their arm and experienced pain in their side and lower back. Despite the facility nurse’s recommendation for hospital transport, R1’s responsible party declined medical services. The DRCS further indicated that on September 26, 2024, the nurse became concerned when R1 refused to get out of bed for breakfast or lunch. The facility nurse contacted R1’s responsible party to express concerns that R1 may have been experiencing pain from the September 21, 2024. In an interview, R1’s responsible party confirmed that on September 21, 2024, R1 expressed having pain in their hip and lower back but noted that this had been an ongoing issue. The responsible party admitted they were unsure whether they made the right decision by not taking R1 to the hospital after the fall. They also acknowledged that there had been instances when facility staff suggested R1 be transported to the hospital, but they were unwilling to do so every time R1 fell if there were no visible injuries or complaints of pain. A review of hospital records dated September 27, 2025, revealed that upon arrival, R1 was diagnosed with acute fractures in ribs 8–11 on the left side and subacute fractures on the right side. Based on a review of the evidence, the licensee did not immediately telephone 9-1-1 for R1, who had fallen, was expressing pain, and could not get out of bed due to experiencing extreme physical pain, solely because R1’s responsible party verbally refused medical care. While residents have the right to refuse medical care, the licensee remains responsible for ensuring that appropriate medical care is arranged. In this case, R1 would have had the right to refuse care against medical advice (AMA) in the presence of emergency medical technicians (EMTs) and/or emergency room medical professionals. Based on the Department’s investigation, the licensee was found in violation. A citation under California Code of Regulations, Title 22, Division 6, Chapter 8, is issued on the attached LIC 809-D. The licensee was informed that a civil penalty might be assessed based on Health and Safety Code 1569.49(f). An exit interview was then conducted with Memory Program Coordinator, Aiyana Martinez. The report was reviewed, and a plan of correction was jointly developed. At the conclusion of the visit, Memory Program Coordinator, Aiyana Martinez was provided with copies of the report, LIC 811 – Confidential Names List identifying Resident #1, and LIC 9058 – Licensee/Appeal Rights. The signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Mar 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Mar 29, 2025

Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health...except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by: Based on interviews and records review the licensee did not call 9-1-1 on September 21, 2024, and/or on September 26, 2024, for 1 [R1] out of 158 residents, which posed an immediate health and safety to residents in care.the state’s words, verbatim · CDSS document, Mar 28, 2025

Plan of correction: Memory Program Coordinator, Aiyana Martinez contacted the Executive Director via telephone and agreed to have staff trained on calling 911 for timely medical care. Proof of scheduled training by POC due date and submit proof of training within 2 weeks.

Allegation investigated: Staff are not ensuring residents are provided with sufficient amounts of food Staff provide dirty dishware to residents

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to commence a complaint investigation. LPA identified herself and discussed the allegations mentioned above with Executive Director, Tracy Knepple. During the investigation, the facility was briefly toured, and interviews were conducted with staff, residents, and outside sources. It was alleged staff are not ensuring residents are provided with sufficient amounts of food in the memory care unit. Today, 03/26/25, LPA observed lunch being served to the residents. There was a hot food cart brought over by the main kitchen. The hot food cart contained large trays of different food items for the residents, which needed to be portioned out and served individually to each resident. Today, the hot food cart had a large tray of yams, roasted vegetables, and salmon. The salmon was shredded up into small pieces. Per the kitchen staff, the salmon is a 4oz fillet. The kitchen has been made aware to serve the items whole, unless there is a modified diet on file. Continued on an LIC 9099C. Substantiated The Enrichment Leader in memory care has a menu order form and will ask each resident what they would like to eat. The Enrichment Leader will write everyone’s order on the form and provide the order form to the kitchen staff. The kitchen staff prepare the food and take it over to the memory care unit on a hot food cart. Staff interviews revealed once the food is brought over, they portion it out and serve it to the residents on a plate. However, staff stated there is not always sufficient amounts of food. For example, today, the salmon was shredded, and each side item was in a large tray, as well as the salmon. The caregiver had to ration out the amount of food on each resident plate to ensure all residents were provided food. LPA observed the staff paying attention to each food item they placed on each plate, while checking the dining room to see how many more residents needed a plate. If the salmon was served as a 4oz fillet, each resident would have received a decent size portion. However, due to kitchen staff cutting up the salmon as well as other food items, the staff have to try and ensure all residents receive a plate of food. LPA observed the large trays after the food was served to the residents and noticed all the food items were finished. Staff confirmed there are times there is not enough food for all the residents and they will have to ask the kitchen staff to bring over more food. The kitchen staff will bring over more food, but it can take thirty (30) minutes. Staff added it’s difficult to have a resident with a Major Neurocognitive Disorder sit at the dining table while other residents are eating, and they must wait additional time. Staff explained due to the resident’s medical condition, they become fidgety and want to get up, which distracts them once the food arrives. Resident interviews confirmed there are times there isn’t enough food served. Outside sources also confirmed there are times during breakfast, lunch, and dinner that there isn’t enough food. Outside sources reported usually the breakfast time is the meal that typically has insufficient food, which was also confirmed by staff. Staff interviews revealed it can depend on which staff member is cooking that day and what they send over to memory care, instead of consistent meal portions. Staff and outside sources also confirmed the kitchen will send over a sandwich and cut each sandwich into pieces and that will be shared amongst residents. There are residents in memory care with a small appetite and some with a regular appetite. Therefore, residents should be served one daily serving as offered on the facility’s menu. The kitchen staff should be consistent with sending whole meals over to the memory care unit, to ensure each resident is provided the quantity necessary to meet the residents needs. Executive Director, Tracy Knepple explained the residents receive enough food to meet their nutritional value. If additional food is needed, the kitchen is always open and able to provide enough food to meet the residents needs. Continued on an LIC 9099C. It was also alleged, staff provide dirty dishware to residents. It was reported cups contain lipstick stains and plates contain crusted food from previous use. Today, 03/26/25, during lunch service in the memory care unit, LPA observed staff taking clean plates and clean cups out of a plastic carrier, which was brought over by the kitchen staff. The items were previously washed and ready for resident use. LPA observed the staff taking the cups out and two (2) cups were placed to the side, due to having lipstick stains. Staff explained they do not serve the dirty dishware to residents. They send it back to the kitchen and make them aware. Staff also explained the dishwasher was broken for approximately one (1) to two (2) weeks and the three (3) sink method was performed. However, the dishwasher has already been repaired and the cups were dirty today, 03/26/25. Executive Director, Tracy Knepple explained staff are trained and if the item is unsafe they know not to provide it or serve it to the resident. Based on LPA’s observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Mar 26, 2025 · control 08-AS-20250318170800

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Apr 23, 2025

General Food Service Requirements. The total daily diet shall be...in the quantity necessary to meet the needs of the residents...meet the Recommended Dietary Allowances... All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not ensure the food quantity met the needs for 25 out of 154 [R1-R25] residents, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2025

Plan of correction: Executive Director stated training will be provided to staff regarding quantity necessary to meet the needs of the residents.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(30) · Plan of correction due date: Apr 23, 2025

General Food Service Requirements. All utensils used for eating and drinking and in preparation of food and drink, shall be cleaned and sanitized after each usage. This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not ensure cups were cleaned for 25 out of 154 [R1-R25] residents, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2025

Plan of correction: Executive Director stated staff will be trained on proper cleaning and sanitation of utensils, dishware and cups.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management – Other visit. LPA met with Executive Director, Tacy Knepple and discussed the purpose of the visit. The facility self reported an incident regarding Resident #1 (R1). On July 7, 2024, R1 was witnessed falling from the third floor balcony of the facility. The facility contacted 911 immediately after discovering R1. R1 was transported to hospital for further medical evaluation. On July 12, 2024, the resident passed away at the hospital. During the investigation, the facility was toured, records reviewed, and interviews conducted with staff, residents, and outside sources. R1’s Preplacement Appraisal dated July 24, 2023, indicated R1 had a Major Neurocognitive Disorder, was very impulsive, and lacked awareness of objects/obstacles close by. The appraisal did not reflect suicidal ideations. R1’s Physician Report dated October 19, 2023, indicated R1 was ambulatory, confused, depressed, unable to communicate needs, and required assistance with bathing, dressing/grooming, and toileting. R1 resided in the Assisted Living (AL) portion of the facility. The facility documented the Major Neurocognitive Disorder and determined R1 was safe and did not require their secured memory care unit. Based on the facility’s assessments, R1 did not have exit seeking behaviors. In addition, R1’s family member’s interview revealed they did not want R1 in the secured memory care unit, as R1 was doing well and progressing with the program. R1 was part of a program called Circle of Friends at the facility. The program was designed as a bridge from AL to memory care. Residents have the ability to attend the program and live in AL, while attending activities to assist with continued independence. Once the resident is no longer able to attend the program due to increased confusion/memory loss or exit seeking behavior, they may transition into the memory care unit. Circle of Friends is located on the third floor of the building, with balcony access. Staff interviews confirmed they were not aware of any suicidal ideations. A review of resident records did not reflect any suicidal ideations but indicated depression. Continued on an LIC 809C. R1 was receiving medical treatment and medication for the depression. Outside source interview revealed R1’s family member was aware R1 was having difficulty. The outside source reported R1 was hallucinating, stating people were coming after them and trying to kill R1. They also reported R1 was getting up in the middle of the night and walking the halls to get away from the voices and people watching R1. R1 admitted to the outside source that they wanted to jump out of a window. The outside source admitted they did not report the concerns to the facility’s management. The outside source stated they told a caregiver and assumed it would be passed on to management. Staff interviews denied receiving knowledge from outside sources regarding R1’s paranoia or hallucinations. Interviews and records corroborated that facility staff, and physician did not document instances of suicidal ideations. The facility conducted five separate appraisals August 25, 2023, September 29, 2023, October 19, 2023, January 11, 2024, and June 9, 2024, the only change noted on the assessments was for stand by for assistance while showering, not for mental status. Further staff and outside source interviews reported R1 was thriving in the program and did not see a need to relocate R1 to the memory care unit. The County of San Diego Death Certificate dated July 15, 2024, indicated cause of death was blunt force trauma with pelvic fractures. The manner of death could not be determined. Based on the Department’s investigation, there was insufficient evidence to deem the licensee culpable of violations of CCR Title 22. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tacy Knepple whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Jan 30, 2025

Allegation investigated: Staff did not ensure supervision was provided resulting in resident elopement

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to commence a complaint investigation. LPA identified herself and discussed the allegations mentioned above with Executive Director, Tracy Knepple. During today's visit, LPA briefly toured the facility, and interviewed staff and residents. It was alleged staff did not ensure supervision was provided resulting in resident elopement. It was reported that on 11/04/24 at approximately 5:30am, an outside source observed a woman with gray hair wearing a floral bathrobe opened up and no brassiere, walking down the street by the facility. The outside source was unable to confirm if the woman was a resident at the facility and continued to drive away without assisting the woman. The Executive Director's (ED) interview revealed there were no resident elopements on 11/04/24. Staff interviews confirmed there were no elopements on 11/04/24. Resident interviews stated they were not aware of any elopements and denied eloping from the facility. Continued on an LIC 9099C. Unsubstantiated LPA reviewed video footage for 11/04/24, there were no female residents leaving or entering the building from 4:45am to 6:45am. Both exits that are not secured were reviewed and determined there was no resident elopement. LPA also reviewed the sign in and out log, which did not include any female residents, for the date and time in question leaving or entering the facility. During the course of the investigation interviews were conducted. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Nov 13, 2024 · control 08-AS-20241108133911

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Natasha Persud conducted a Case Management - Incident visit. LPA met with Executive Director, Tracy Knepple and discussed the purpose of the visit. During today's visit, LPA briefly toured the facility, requested records, and interviewed staff. The facility self reported an incident involving Resident #1 (R1). The report indicated on 10/22/24, R1 was found by an outside source on the front sidewalk near the parking lot, no injuries sustained. The facility was not aware R1 left the facility. The facility has a concierge at the front desk. However, the concierge did not notice R1 exiting the front door. R1's Physician's Report reflected R1 is not allowed to leave the facility unassisted and has a Major Neurocognitive Disorder. Per the Executive Director (ED) they were unable to redirect R1 after the incident and sent R1 out for a medical evaluation. The ED stated based on observations of R1, they believed there was a medical reason for the condition, as this was the first occurrence with R1. The ED explained R1 will be assessed upon return. In addition, ED discussed with the concierge the importance of acknowledging all people entering and exiting building at all times. The concierge was reprimanded and provided correction action. Based on interviews, a deficiency was cited on the attached LIC 809D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Oct 28, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312 · Plan of correction due date: Nov 25, 2024

Basic services requirements. Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by: Based on interviews, the licensee did not ensure the safety for 1 out of 155 residents [R1] when R1 eloped from the facility without staff knowledge, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 28, 2024

Plan of correction: Executive Director (ED) stated they will conduct in-service to all concierge staff regarding being aware of all individuals entering and exiting the building, especially residents that cannot leave unassisted. In addition, ED stated the concierge was give correction action. ED will submit proof of training by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Natasha Persud conducted a Case Management - Incident visit to check on the health and safety of residents in care. LPA met with Executive Director, Tracy Knepple. During today's visit, LPA briefly toured the facility, collected records, observed resident's in care and spoke with staff concerning the health and safety of residents. LPA did not observe any immediate health and/or safety violations and after speaking with residents did not receive any complaints about their health. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Oct 15, 2024

Allegation investigated: -Facility did not provide adequate food service resulting in resident becoming ill -Facility is not clean and in good repair

Licensing Program Analyst (LPA), Natasha Persaud conducted a visit to conclude the complaint investigation regarding the above-mentioned allegations. LPA met with Executive Director, Tracy Knepple. During the investigation, records were reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged the facility did not provide adequate food service resulting in resident becoming ill. An outside source reported that on 8/15/2024 around noon, they had lunch with their friend/resident at the facility. Both individuals became ill, with symptoms including vomiting and diarrhea, and it was suspected it was due to the salmon served at lunch. Neither individual sought medical attention nor were aware of anyone else getting sick. Multiple caregiver interviews revealed they eat the food served at the facility and have never gotten ill. The Chef Manager was observed on 08/28/24, eating the salmon served by the facility. The Chef Manager explained he eats the food all the time and loves the salmon and has never gotten ill. The Chef Manager also explained the food only sits in the warmer for two (2) hours or less. Continued on an LIC 9099C. Unsubstantiated There are no concerns for bacteria or food poisoning. Resident interviews confirmed they have not gotten ill from the facility food. The Executive Director also confirmed eating the facility’s food on a regular basis and never gotten ill. It was also alleged the facility is not clean and in good repair. An outside source reported that on 8/19/2024 they were informed that the kitchen was very dirty, and several kitchen equipment items were broken. The outside source confirmed they did not observe the kitchen. The Chef Manager’s interview revealed there was a Low Boy fridge out of service. The didn't use the Low Boy and it was thrown out and a new one was delivered within 2 weeks. The Chef Manager also stated the staff clean the kitchen daily, wiping down, sweeping, mopping, and sanitizing. LPA observed the kitchen on 08/28/24, all equipment was in good repair and working order, and the kitchen was clean. Residents were not interviewed because they do not enter the kitchen. The Executive Director (ED) stated if equipment is broken it’s immediately repaired or replaced. The ED confirmed the Low Boy fridge was broken and a new one was ordered and delivered on 07/31/24, which was prior to the reported date of incident. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations were deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 08-AS-20240822100509

Allegation investigated: -Staff did not follow resident's care plan -Staff did not respond to resident in a timely manner -Licensee did not arrange appropriate medical care for resident

Licensing Program Analyst (LPA), Natasha Persaud conducted a visit to conclude the complaint investigation regarding the above-mentioned allegations. LPA met with Executive Director, Tracy Knepple. During the investigation, records were reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged staff did not follow resident's care plan. It was reported Resident #1 (R1) was receiving the highest level of care the facility offered. The level of care included two (2) persons assist but the facility was not following that. Outside sources also reported R1’s family members had to help with transfers as the facility was not providing the agreed service. R1’s Admission Agreement dated 03/03/21 confirmed the level of care being provided was Enhanced Personal Care II (EPC), which was the highest level the facility provided. The EPC II refers to all activities of daily living, to inclue two (2) persons assist. R1’s Assessment and Service Plan dated 03/03/21 reflected R1 required assistance with dressing, grooming, toileting, transfer assistance by two (2) staff members, and medication management. R1’s showers were provided by hospice. Continued on an LIC 9099C. Substantiated Executive Director, Inan Linton stated R1 was non-weight bearing with full assistance of activities of daily living, when released from a skilled nursing facility to their facility. ED Linton also stated R1 was not a two (2) person assist but needed assistance with either a stand/sit or Hoyer lift device. However, R1’s Preplacement Appraisal dated 03/03/21, signed by ED Linton indicated R1 required assistance with transfers, bathing, dressing/grooming, moving about the facility, toileting, and medication management. The appraisal does not address two (2) persons assist. R1’s Physician’s Report dated 02/19/21 indicated R1 was bedridden and required assistance with all activities of daily living. Staff interviews revealed R1 was not two (2) persons assist. Staff stated R1 used a walker and would walk around their room and go to the bathroom on their own. Staff also stated R1 required assistance with going to the bathroom for safety reasons. According to statements made by staff, they were not following the facility’s Assessment and Service Plan dated 03/03/21, which required transfer assistance by two (2) staff members for R1. It was also alleged staff did not respond to resident in a timely manner. Outside source interview revealed R1 had to wait over 30 minutes, and up to 45-50 minutes to get help with the bathroom. A review of R1’s Response Time document, also known as Call Button Log dated 03/04/21 thru 03/31/21 indicated multiple responses over thirty (30) minutes. On 03/05/21 response time 45 minutes 52 seconds; 03/06/21 response time was 1 hour 30 minutes; 03/08/21 response times were 42 minutes 7 seconds and another for the same date of 51 minutes 35 seconds. On 03/11/21 response times were 33 minutes 50 seconds and another for the same date of 40 minutes 8 seconds. On 03/18/21 response time was 31 minutes 55 seconds; 03/27/21 response time of 32 minutes 19 seconds; and 03/30/21 response time 59 minutes 5 seconds. Staff interviews confirmed some staff did not respond timely due to not wanting to assist residents. Resident interview confirmed late response times and having to sit in soiled diapers until the NOC shift arrived as staff came within 24 hours to check on residents during that time frame. Continued on an LIC 9099C. Lastly, it was alleged the licensee did not arrange appropriate medical care for resident. Outside source interview revealed R1 required a second Covid 19 vaccine and the facility did not arrange appropriate medical care for R1. Executive Director (ED), Inan Linton explained R1 received their first dose of the Pfizer covid-19 vaccine at the Skilled Nursing Facility (SNF) prior to admission of the facility. However, the SNF could not administer the second dose due to resident receiving a TB test, which was required to be admitted to the facility. R1 was not provided the second does at the facility’s third Covid-19 clinic on 03/06/21, due to being told that R1’s Hospice agency was administering the vaccine. However, hospice never administered the second dose, so the facility was calling around trying to find an appointment. According to ED Linton they continued to call multiple places and found a superstation in Campo, California, which was 45 minutes away, but the only availability. The Director of Resident Care Services (DRCS) at the time signed R1 up online. During sign-up, it asked which vaccine needed, the DRCS responded, Pfizer, then the appointment was scheduled. The day of the vaccine appoint, the facility provided transportation and R1’s son accompanied them, due to R1 recovering from a fractured back. The driver called ED Linton, while at the superstation that the resident was unable to receive the vaccine as the superstation was only providing Johnson and Johnson vaccines. ED Linton started calling other locations and found one at a nearby licensed facility. The appointment was scheduled and R1’s son accompanied them. When they arrived at the licensed facility, CVS refused to administer the vaccine because they said per CDC guidelines too much time had passed. ED Linton started calling physicians and found one that came to the facility and administered the second dose of the Pfizer vaccine, to R1in their room. Based on ED Linton’s interview they did not arrange appropriate medical care for R1. The DRCS should have confirmed the vaccine being provided before the resident was transported 45 minutes away. Also, ED Linton and/or DRCS should have been aware of the CDC guidelines regarding the Covid 19 vaccination. Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights. R1 was not exposed to anything hazardous. Interviews conducted with residents expressed no issues or concerns with rooms. Staff interviews revealed many rooms were being renovated at the time. However, staff did not recall issues with R1’s room. Even though the room may have been full of paint chips and plaster dust, the facility kept R1 in the hallway, while the room was prepared. Therefore, R1 was not exposed to anything hazardous. It was also alleged staff did not provide food to meet the resident's needs. Outside source interview revealed the food was delivered cold and late; and half the items were missing for R1. Staff interviews revealed they take the order from the resident in a computer system that is generated directly to the kitchen. Staff interviews stated there were no issues with food. Staff interviews also revealed R1 would be asleep, and the food was delivered, covered in saran wrap and placed on R1’s bedside table. Staff would then wake R1 and state the food was there and R1 would open their eyes. R1 would sleep then wake up and complain the food was cold. Further staff interview revealed R1 would order a soup, main entree, and celery/carrots. R1 would eat the soup while watching television then eat the celery/carrots, by then the main entree was cold. Staff would still offer to reheat the food. Resident interviews revealed the food was cold, never even lukewarm. Residents were able to use their microwave to reheat the food. Staff also confirmed heating resident’s food up for them if needed. During Covid 19 most facilities were having issues. Even though the food may have been served cold, the resident’s had the ability to warm their food in their microwave. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations were deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 08-AS-20210513114116

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 17, 2024

Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure staff were competent with following through with care plan for 1 out of 123 [R1] residents, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Executive Director stated In-Service training will be conducted with staff regarding following resident care plans.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Oct 17, 2024

Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure staff respond timely to 1 out of 123 [R1] residents’ requests for assistance were over 30 minutes for staff to respond to and restore pendants, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Executive Director previously conducted In-Service training regarding Ciscor Call System Response and submitted proof of training. POC corrected.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Oct 17, 2024

Incidental Medical and Dental Care. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not arrange appropriate medical care for 1 out of 123 [R1] residents. R1 was taken to multiple locations for a vaccine due to staff not confirming appropriate appointment, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Executive Director stated the management team assists and arranges medical care for residents in need. There have been no issues since the former staff involved is no longer working at the facility. POC corrected.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management -Other visit. LPA met with Executive Director, Tracy Knepple. On 08/01/24, the facility applied for a secured perimeter. There was a delay with the Fire Department granting an incorrect reason instead of secured perimeter. On 09/13/24, the Fire Department revised the fire clearance and approved the facility for secured perimeter. LPA toured the facility's perimeter and observed it was locked and secured. No deficiencies were observed during today's visit. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Sep 26, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management visit - Other. LPA met with Executive Director, Tracy Knepple. Today, LPA was at the facility for an investigation. During the resident interviewing process. LPA observed Resident #1 (R1) sitting in the common area near their apartment. LPA approached R1 and they stated they were not feeling well and had Covid-19. R1 also had their apartment door open, allowing exposure. The facility did not follow their infection control guidelines by ensuring the resident was isolated. The Executive Director was made aware of R1 sitting in the common area. The ED requested R1 to return to their apartment and explained keeping other residents safe. The ED also stated she will have staff conduct rounds to ensure Covid-19 positive residents are isolated per infection control guidelines. A deficiency was issued and cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Aug 28, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(b)(3) · Plan of correction due date: Sep 4, 2024

Infection Control Requirements. There shall be separation and care of residents whose illness requires separation, including quarantine or isolation, from others. This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not ensure Covid positive residents are isolated for 1 out of 156 residents [R1], which could pose a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2024

Plan of correction: Executive Director stated staff will be trained on infection control requirements. Proof of training will be submitted by POC due date.

Allegation investigated: Facility staff did not follow physician's orders

Licensing Program Analyst (LPA), Natasha Persaud conducted a complaint investigation regarding the above-mentioned allegation. LPA met with Executive Director, Tracy Knepple. During the investigation, LPA toured the facility, reviewed records, and interviewed staff, residents, and outside sources. It was alleged the facility staff did not follow physician's orders. It was reported Resident #1’s (R1) Consistent Carbohydrate Diet (CCD) was not being followed. R1’s Physician’s Report dated 12/08/23 indicated R1 required a low no added salt diet. On 06/17/24, R1’s physician wrote an order for a “Low-carb diet and decaf coffee only.” The Executive Director (ED) explained the facility received a copy of the order and it’s entered in the computer system to alert the kitchen of the requirement. The ED’s interview revealed the facility offers six (6) diets and Low carbohydrate falls under the category of CCD. ED also explained the facility does not add salt to their food. Therefore, the physician’s report indicating no added salt is also being complied. Continued on an LIC 9099C. Unsubstantiated ED stated Belmont’s corporate staff and a dietician designed the menu to ensure all options are low carbohydrates, excluding the beverages and desserts. The ED explained the admission agreement outlines the diets offered at the facility, prior to the resident and/or responsible party signing. The Director Resident Care Services (DRCS) indicated all menu options have moderate carbohydrate amounts and is proportioned appropriately. R1 requires carbohydrates and the order does not state no carbohydrates. DRCS confirmed the menu is tailored to accommodate a low carbohydrate diet for all residents. DRCS explained the facility does not offer a diabetic diet. Therefore, a resident would have to relocate to an appropriate facility that accommodates a diabetic diet. Outside source interviews revealed R1 was being served waffles with syrup, hamburgers, and baked potatoes. Outside source interviews also revealed R1 sits at the dining table and eats multiple sugar packets. The outside source would like the sugar packets removed from the table. However, that would be a violation of residents’ personal rights. DRCS confirmed the high sugar content items on the menu would be the beverages and desserts. The staff will offer sugar free options for beverages and desserts. However, they cannot force the resident to choose sugar free options, especially since the facility does not offer a diabetic diet. The Chef Manager’s interview revealed the menu offered to residents consists of no added salt and low carbohydrates. The Chef Manager also confirmed the portions are not the portion sizes served at a restaurant. The facility serves potatoes that are small, approximately 3oz; the waffles are mini size and only two (2) are served; and the burger is approximately 2-2.5 oz. Therefore, the resident can select any of the items due to the low carbohydrate content and portion size. Chef Manager also stated the server is aware of any special/modified diets and they will offer the resident sugar free syrup, other sugar free options, and will also try to persuade the resident to make good choices. However, the resident has personal rights and is allowed to choose any items. If the staff notice a resident isn’t making wise choices, such as ordering double portions then it’s reported to the nurse for follow up with the resident’s physician. There have been no issues with R1, they select their own meals and eat in the dining room. Facility’s correspondence dated 06/17/24 indicated R1’s responsible party wanted the facility to stop serving breads, pasta, cookies, potatoes, sugar packets, sugary drinks/desserts. However, R1 requires carbohydrates per the physician’s order. Also, R1 has the cognitive ability to make their own food choices. The facility is offering a low carbohydrate diet and R1 has the right to make their own choices. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Aug 21, 2024 · control 08-AS-20240804095825

Type of visit: Collateral

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced Collateral visit for an investigation unrelated to this facility. LPA identified herself and was granted entry by Diane Forsythe, concierge. LPA met with Tracy Knepple, Executive Director, and discussed the purpose of the visit. During today’s visit, LPA requested and obtained records (see LIC811 Confidential Names list). There were no deficiencies observed or cited during today’s visit. An exit interview was conducted with Tracy Knepple, Executive Director, to whom a copy of this report, LIC811, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Aug 21, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and met with Executive Director (ED), Tracy Knepple. LPA, accompanied by ED and staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured between 108 degrees and 116 degrees F.. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. A Pool was observed on the premises and locked in accordance with regulations. Per the ED, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. The facility was equipped with delayed egress and secured perimeters in Dementia Unit. However, the facility has locked the entire perimeter for safety reasons, which is a violation of the fire clearance. Continued on an LIC 809C. LPA reviewed multiple staff and resident records/files. The reviewed files contained required documents. Confidential records were stored in locked areas. A deficiency was observed and cited during today's annual inspection. A civil penalty was assessed for a fire clearance violation. The ED has already submitted documentation requesting a new fire clearance for secured perimeter for the entire facility. An exit interview was conducted with Executive Director, Tracy Knepple to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jul 30, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Incident visit. LPA met with with Executive Director, Tracy Knepple. The facility self reported an incident regarding Resident #1 (R1). On 07/07/24, the facility's Licensed Vocational Nurse (LVN) was witnessed being rude and not treating R1 with dignity. R1 was receiving hospice services and it was not safe for R1 to get up from bed. R1 also has a private companion hired by the family. The LVN raised their voice at facility staff in front of R1 and R1's private companion regarding not being allowed to get up from bed. The ED stated they honor resident's wishes regardless of their physical state. The LVN also made inappropriate comment towards R1, by referring to R1 as a child. The Executive Director's interview confirmed that it is the expectation to honor resident's wishes, including requesting to use restroom or to get out of bed, even if there may be difficulty or obstacles. The facility also self reported another incident regarding Resident #1 (R1). The facility provides medication management for R1. On 07/08/24, the Medication Technician documented R1 refused their medications. R1's family stated that they had video coverage of the room and no one entered or attempted to provide R1 with medications. The Medication Technician falsified the Medication Administration Record and documented R1 refused the medications. R1 did not receive their medications during the AM shift. The facility was proactive and conducted In-Service training for all staff members who are involved with medication administration. The Executive Director stated action was taken immediately once made aware of the incident to ensure the two staff were no longer involved with resident care. The LVN and the Medication Technician were terminated. Deficiencies were cited today on the attached LIC 809D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1].the state’s words, verbatim · CDSS document, Jul 16, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 13, 2024

Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews and record review the licensee did not ensure 1 out of 159 [R1] residents received medications as prescribed, which was a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: The Executive Director provided proof of medication training that was conducted on 07/12/24, POC cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.1(a)(1) · Plan of correction due date: Aug 13, 2024

Personal Rights of Residents in All Facilities. To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews and record review the licensee did not ensure 1 out of 159 [R1] residents were not treated with dignity which was a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: The Executive Director stated Personal Rights training will be conducted and proof of training will be provided by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Incident visit. LPA met with with Executive Director, Tracy Knepple. Today, the facility was briefly toured, records requested and interviews conducted with staff and resident. The facility self reported an incident regarding Resident #1 (R1). On 07/12/24, R1 was witnessed falling from the third floor balcony of the facility. The facility acted appropriately and contacted 911, R1 was transported to hospital for further medical evaluation. R1 passed away at the hospital the same day. No deficiencies were issued today. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1].the state’s words, verbatim · CDSS document, Jul 16, 2024

Allegation investigated: Licensee did not ensure food is of good quality Licensee did not ensure resident records are current

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegations. LPA met with Director of Resident Care Service, Keisha Bean. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged the licensee did not ensure food is of good quality by serving burnt, overcooked and undercooked food. The food is cooked and prepared in the main kitchen then delivered to memory care. The breakfast was observed on multiple occasions by staff being of poor quality and returned to the main kitchen. Staff interviews confirmed the bacon was burnt, eggs were watery and green, and the pancakes were powdery. Further staff interviews revealed the main kitchen complains that too much food is being sent back. The main kitchen also sends over hard meat and veggies that are not cooked, which those are hard for residents to eat. Continued on an LIC 9099C. Substantiated Staff also reported they can return the food items and request better quality. Executive Director’s interview revealed they recently had to hire a new cook due to unforeseen circumstances. However, ED has not heard of food complaints and believes the cook is doing a good job. It was also alleged the licensee did not ensure resident records are current. Title 22 Regulations require residents with a diagnosis of a Major Neurocognitive Disorder have an annual medical assessment. A review of records indicated Resident #1 (R1) and Resident #2 (R2) both have a Major Neurocognitive Disorder did not have current medical assessments. R1’s Physician’s Report was dated 08/18/22 and R2’s Physician’s Report was dated 07/12/21. The Physician’s Reports were collected on 02/09/24. Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Director of Resident Care Service, Keisha Bean whose signature below confirms receipt of these rights. Outside sources reported staff were using thickener powder for R2’s water due to R2 repeatedly requesting water. Staff interviews revealed R2 tends to repeatedly ask for water due to their medical condition. Further staff interviews confirmed R2 was provided water when requested but also monitor R2’s water consumption for safety. Staff also stated a prescription was needed for thickener power, which R2 does not have. Staff denied using thickener powder. On 02/09/24, LPA observed R2 repeatedly requesting water and receiving it. R2’s interview confirmed they are being provided water upon request. It was reported R3 was being kept from going to their room. Staff interviews stated residents are encouraged to participate in activities and they prefer residents in the common areas. However, residents can go to their room any time. All residents are provided with a key to their room. The resident rooms lock automatically to prevent wandering residents. The residents have a Major Neurocognitive Disorder and are assisted to their rooms by staff or can independently go to their room. R3’s interview confirmed they are not being kept from going to their room. On 02/09/24, LPA observed R3 requesting to go to their room and staff assisted. It was also reported R4 was being denied bathroom use. Staff interviews revealed R4 has a medical condition that makes R4 believe they have to frequently use the bathroom. Staff interviews also revealed the facility was working with R4’s family regarding the urgency to use the bathroom. On 02/09/24, LPA observed R4 request an escort to use the bathroom. Staff assisted R4 to their bedroom to use the bathroom. Once R4 was done and returned to the common area, they immediately asked to use the bathroom and commented they never used the bathroom. R4’s interview confirmed they can use the bathroom whenever they like. It was also alleged staff did not treat residents with dignity. It was reported R1 was called an inappropriate word by staff and told hurtful things about R1’s family members. Also, R3 will repeatedly ask the same question due to their Major Neurocognitive Disorder and told by staff that their parents were dead, each time R3 asks for them. Resident interviews revealed denial of being called inappropriate words or being told anything negative about their families. Staff interviews confirmed they are not using inappropriate words or negative comments towards residents. It was also alleged staff did not allow residents to use their own personal possessions. It was reported Resident #5 (R5) was denied the use of their eyeglasses. Continued on an LIC 9099C Staff interviews revealed R5 has many pairs of eyeglasses and will set them down in different places due to their forgetfulness. Therefore, the family bought R5 multiple pairs. The eyeglasses are not prescribed by a physician, but store-bought reading glasses. On 02/09/24, LPA observed R5 was wearing a pair of glasses and had a pair hanging from the middle of their sweater. R5’s interview revealed they always have access to their eyeglasses. It was also reported Resident #6 (R6) was being denied access to their hearing aids. Staff reported R6’s hearing aids are kept at the desk of the Director of Memory Care for safety and charging. Staff’s interview confirmed they are aware of the process for R6’s hearing aids. Outside source interviews confirmed staff charge R6’s hearing aids then bring them for R6 daily. Outside sources also stated there were times the hearing aids were not charged. However, R6 was never denied the use of them. On 02/09/24, LPA observed R6 was wearing charged hearing aids. It was also alleged staff did not meet residents’ hygiene needs by not showering and changing residents’ clothing for days. Staff interviews revealed residents are showered according to their shower schedule and clothing is changed daily. Outside source interviews revealed R5 has worn the same clothing for two to three days consecutively. Staff interviews stated R5 has trouble seeing and will usually spill food on their clothing. However, R5’s clothing is changed daily. Additional outside sources revealed R6 was observed in the same clothing for three days consecutively. However, it was a one-time occurrence. On 02/09/24, LPA observed R5 had food spilled on their clothing, staff confirmed R5 just had lunch. LPA also observed R6, who was clean and dressed well. LPA has observed R6 on multiple occasions while visiting the facility and R6 was kept clean. Residents are being showered accordingly and clothing changed daily. Resident interviews confirmed they are being showered and clothing changed daily. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Director of Resident Care, Keisha Bean whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Residents 1-6]the state’s words, verbatim · CDSS document, Jun 27, 2024 · control 08-AS-20240202133159

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Jul 18, 2024

General Food Service Requirements. The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents...the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Based on interviews, the licensee did not ensure good quality of food for 21 of 147 [R1-R21] residents, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 27, 2024

Plan of correction: Director of Resident Care Services stated the facility will implement a policy along wth training to ensure the kitchen lead inspects and verifies food is of good quality prior to sending to memory care. Proof of policy and training due by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Jul 18, 2024

Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Each resident...shall have an annual medical assessment...of the resident’s dementia care needs. This requirement is not met as evidenced by: Based on record review the licensee did not ensure medical assessments were current for 2 out of 147 [R1-R2], residents, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 27, 2024

Plan of correction: Director of Resident Care Services stated they will provide a current Medical Assessment for residents #1 and #2 by POC due date.

Allegation investigated: Staff do not respond timely to residents’ calls for assistance

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above-mentioned allegation. LPA met with Director of Resident Care Service, Keisha Bean. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged staff do not respond timely to residents’ calls for assistance. LPA reviewed the facility’s log of resident requests for assistance initiated via individually assigned pendants. The review of requests that were initiated on November 1, 2022, through December 15, 2022, revealed that in response to five (5) resident requests initiated via pendant, had response times from (1) minute to one (1) hour and forty (40) minutes. There were multiple occasions where more than thirty (30) minutes elapsed before resident pendants were restored. Based upon a review of records maintained by or on behalf of the facility, on that date, wait times were unreasonably long, and resident requests for assistance were not responded to in a timely manner. Continued on an LIC 9099C. Substantiated Resident interviews revealed sometimes it take a long time for staff to respond but they understand they are assisting other residents. The Executive Director’s (ED) interview revealed there is one (1) caregiver per twenty-four (24) residents, which is two (2) hallways- 2nd floor. However, the second floor has independent residents and residents that require assistance. The facility also has a floater staff, and they utilize a staffing agency daily. The ED also stated It's not typical for the staffing agency to cover the hallway on their own. They will move staff around to assist, such as the floater or from another floor because the staff from the agency understand basic care giving but not necessarily the resident's routine. Outside source interviews revealed a family member was visiting a resident and staff were not responding, which was over 30 minutes. Therefore, the family member had to search for a staff member to assist. Additional outside sources indicated some residents are full assist which can take one (1) hour for resident’s tasks so it's difficult for staff to get to everyone timely. Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Director of Resident Care Service, Keisha Bean whose signature below confirms receipt of these rights. Then the NOC shift comes in and they do shift turnover and state who needs to be changed or was just changed. ED said staff communicate well during shift turnover. Therefore, residents are not left in wet and soiled diapers. It was also alleged staff did not provide breakfast to residents. It was reported staff are not able to get all the residents up in time for breakfast. Therefore, residents are missing their breakfast. Resident interviews revealed they eat in the dining room and not have missed breakfast due to staff. Staff interviews revealed all residents eat in the dining room or have tray service. Staff stated residents have the right to refuse breakfast, but residents are not missing breakfast due to staff neglect. The ED’s interview revealed the facility does not document missed breakfast because the resident has the right to refuse. If the resident misses two consecutive breakfasts, then it's documented and addressed. There was no documentation indicating breakfast was missed consecutively, as residents were eating. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Director of Resident Care Service, Keisha Bean whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jun 27, 2024 · control 08-AS-20221208115812

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jul 18, 2024

Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on record review, the licensee did not respond to 5 out of 161 [R1-R5] residents’ requests for assistance in a timely manner. Some resident wait times were more than 30 minutes for staff to respond to and restore pendants. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 27, 2024

Plan of correction: Director of Resident Care Service stated they are in the process of implementing a new policy regarding decreased response time. The facility is purchasing new staff communication equipment and providing training on the new policy. The facility will submit new policy by POC due date and provide proof of training once completed.

Allegation investigated: Residents are not receiving medications

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above-mentioned allegation. LPA met with Director of Resident Care Service, Keisha Bean. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged residents are not receiving medications. It was reported multiple residents were not receiving their medications and are given incorrect medications. Staff interviews revealed residents are given their correct medications and there are no medication errors. Resident interviews reflected they believed they were given correct medications but could not be certain. A review of multiple Medication Administrator Records (MARs) for April 2024 reflected medications dispensed and medications not dispensed for various reasons. The MARs have a symbol key indicator, which is documented for the dates the medications were not dispensed or given and initialed by staff. Continued on an LIC 9099C. Substantiated The key indicator had multiple symbols, to include a symbol for “missed dose” and a symbol for “not administered - see notes.” The MARs also have a notes page to reflect the reason the medication was not dispensed. A review of the notes page indicated there were multiple missed doses and as well as not administered. However, no reasons were documented for multiple medications for multiple residents, which confirmed residents are not receiving medications as prescribed. Due to the facility not documenting the reason medications were not dispensed, only that they were not dispensed, confirmed residents weren’t given their prescribed medications. In addition, the MARs reflected not applying a prescribed ointment/cream because staff could not locate it for multiple days. The facility did not ensure residents were receiving all their prescribed medications. There were no reported adverse results from missed and/or not administered medications. Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Director of Resident Care Service, Keisha Bean whose signature below confirms receipt of these rights. Resident interviews confirmed they are being checked on regularly. However, some residents admitted they don’t like being checked on, yet staff continue to regularly check for their safety. It was also alleged staff are not properly trained on transferring residents. Outside source interviews reported staff are not transferring residents correctly with person to person and transfers, as well as transfers with the use of a hoyer lift. The Executive Director’s interview revealed all staff are provided training with all transfers. The ED submitted proof of training for staff regarding transfers. The ED also explained new staff are paired with an existing staff to assist with transfers, to ensure new staff are comfortable with transfers. Staff interviews confirmed they receive training on transfers. Staff also stated they are paired with a staff that has experience. Additional staff interviews confirmed new staff will stay with the experienced staff until they are ready to independently work with the residents that require transfers. Staff also stated there is no set time frame, some staff need three shifts with the experienced staff and some new staff may need a month. The ED allows as much time as needed to ensure staff transfers are done correctly and safely. Resident interviews confirmed staff are transferring them appropriately and had no concerns. Lastly, it was alleged resident’s pendants are in disrepair. It was reported over fifteen (15) pendants were in disrepair. On 05/15/24, LPA interviewed and observed multiple residents and their pendants, none were in disrepair. In addition, all resident rooms have a pull cord in the event of emergency. Also, not all residents are issued pendants, as it based on the level of care provided to the resident. Outside source interviews revealed some resident’s pendant were inoperable. However, some of those reported residents were not issued pendants. Staff interviews revealed sometimes a resident’s pendant will not be working and they take it to concierge and put a work order in. Staff verified the pendant is fixed within twenty-four (24) hours. Additional staff stated if the pendant isn’t working, they take it directly to maintenance and it’s repaired on the spot immediately. The ED and staff stated the issue is usually the battery is low, which is repaired quickly. Outside source interviews revealed a resident’s pendant was inoperable and the facility fixed it within 24 hours. In addition, the outside source stated staff set up the resident’s pull cord in their room in a way the resident would have easy access, while waiting for the repair. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Director of Resident Care Service, Keisha Bean whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jun 27, 2024 · control 08-AS-20240507100826

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 18, 2024

Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review the licensee did not ensure medications were given as prescribed to 4 out of 151 [R1-R4] persons in care which could pose a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 27, 2024

Plan of correction: Director of Resident Care Service stated staff will attend vendor training regarding medication administration and documentation by POC due date.

Type of visit: Case Management - Incident

LPA Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Director of Resident Care Keisha Bean. Today's visit was in response to an LIC 624 Incident Report, which licensee self submitted to the CCLD San Diego Regional Office (received on 06/17/2024). According to the LIC 624: during the morning of 06/11/2024, Resident 1 (R1) exited the facility and walked along the street out front of the facility. R1 was picked up by the facility driver and was returned safely to the community. R1 was assessed by staff with no injuries noted and also met with staff to discuss their reason for leaving. After speaking with the resident, R1 expressed an understanding of not leaving the facility unassisted again and that if they want to leave they will seek assistance. During today’s visit, LPA performed a brief facility tour and collected copies of and reviewed pertinent records. LPA also interviewed relevant staff. According to their latest LIC 602 Physician’s Report (dated 01/29/2024), R1 was diagnosed with Mild Cognitive Impairment (MCI) and required staff assistance with taking their prescribed medications and it is documented that the resident is not able to leave the facility unassisted. An exit interview was conducted with Bean, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jun 20, 2024

Type of visit: Case Management - Other

Licensing Program Manager (LPM) Simon Jacob arrived on June 7, 2024 for an unannounced case management visit to follow up on a substantiated complaint investigation. LPM Simon Jacob met with Director of Resident Care Services, Keisha Bean, and reviewed the report. On May 6, 2021, the Department concluded a complaint investigation which alleged that a resident sustained multiple pressure injuries resulting in hospitalization due to staff neglect. The allegation was substantiated, and the licensee was cited under California Code of Regulations § 87465(g) – Incidental Medical and Dental Care, which states in part, “The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health...” On August 24, 2021, the licensee was also cited, on case management, three violations as a result of the complaint. The first deficiency was cited under California Code of Regulations, Title 22 § 87609(b)(2), Allowable Health Conditions and the Use of Home Health Agencies, which states in part, “Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: The licensee provides the supporting care and supervision needed to meet the needs of the resident receiving home health care.” The second deficiency was cited under California Code of Regulations, Title 22 § 87411(a) Personnel Requirements – General, which states in part, “Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.” The third deficiency was cited under California Code of Regulations, Title 22 § 87616(a), Exceptions for Health Conditions, which states in part, “As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.” At the time of the complaint visit on June 23, 2022, an immediate civil penalty of $500 was assessed and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation. This is evidenced by the licensee’s failure to contact 9-1-1 or obtain emergency medical services when they observed an imminent threat to the health of the resident, failure to obtain a written plan of care from the home health agency and mobile wound care provider for the new and ongoing pressure injuries, failure to conduct a reappraisal, failure to train and supervise facility staff responsible for providing supporting care and supervision, and for failure to ensure staff followed physician’s orders which contributed to the development of the pressure injuries and infection that emitted foul odors and required medical intervention, including hospitalization and maggot debridement therapy. Today, June 7, 2024, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injuries in the amount of $10,000. However, since an immediate civil penalty of $500 was previously assessed on June 23, 2022, the amount of the civil penalty issued today will be $9,500. A copy of the LIC 421D was given to Director of Resident Care Services, Keisha Bean and originals were signed. An exit interview was conducted, a copy of the report was issued, and Appeal Rights were provided. Director of Resident Care Services, Keisha Bean's signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Jun 7, 2024

Allegation investigated: - Facility bathroom was not maintained cleaned

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by receptionist Stephanie Runyon. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director Tracy Knepple. The Department’s investigation consisted of interviews with residents and staff, records review of relevant documents pertinent to this investigation, and LPA observations. On March 30, 2022, it was alleged that the resident’s bathroom was not maintained cleaned. It was alleged that the resident’s bathroom floor had splashes of urine and fecal matter. Interview with residents confirmed that they did not have issues with their bathroom being cleaned or being kept clean. During an interview with the Engineer, who oversees housekeeping, they said that the housekeeping staff has a current schedule posted for the staff on the designated areas they must clean for the day. Unsubstantiated They mentioned that they have a check sheet for the housekeeping staff to review while they clean to ensure the cleanliness of the areas. They also have implemented a survey for the residents to fill out as they want to hear from the residents. The Engineer has a monthly in-service training with staff to ensure they are properly cleaning and one of the current topics was the cleaning of resident’s rooms. Reviewed the in-service training sheet. According to the Housekeeping Team sheet, the topic of Resident Room Cleaning is done twice a year. It goes over how many times per week, the time frame it should take to clean and the number of units that should be cleaned per day. It also goes over the Room Assignment Schedule and the Housekeeping checklist, room cleaning and bathroom cleaning standards. On the back of the training is the Housekeeping Room Cleaning Checklist. Per the job description of the housekeeping position, and a part of their responsibilities is to maintain, clean and sanitize the bathrooms. During the initial visit on 4/05/2022, LPA toured the facility and observed multiple random rooms and their respective lavatories. LPA observed that they were all clean and there was no fecal matter or urine on their floors or around the toilets. During the subsequent visit on 05/28/2024, LPA observed that there were staff who were conducting their cleaning rounds throughout the facility. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during resident interviews and records reviewed, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Executive Director Tracy Knepple. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Executive Director Knepple at the conclusion of the visit. The signature below confirms the documents were received. (Continuation of LIC9099) A tour of the panel was conducted, and they demonstrated what sounded on the panel and where the panel indicated the issue was. Engineer staff provided LPA with the room’s log to where the issue was located. In review of the log, the description verified that the smoke alarm was being triggered each time that the resident would call for staff assistance. In review of the invoice for the services that were performed, it demonstrated that the panels wires had a ground fault and repairs were made to the nurse switches to that specific room. Based on the information obtained, there is sufficient evidence to support this allegation. It was said that the staff provided resident #1 (R1s) medication daily when their primary care physician (PCP) had discontinued a medication from a daily medication to a pro re nata (PRN). In review of the facility’s Medication Administration Record (MAR) the medication that which was incorporated as a routine medication order was dated March 15, 2022. According to the routine medication order, the medication was discontinued on March 26, 2022. In review of the same month’s PRN medication orders listed the same medication on R1’s MAR as a PRN and provided to R1 as a PRN for the dates of March 15 – 19, 22, 27 – 29, and 31, 2022. According to the Discontinuation Orders, this medication was discontinued twice. The first on 3/04/2022, but the MAR indicated that it was not due. The second time this medication was discontinued was on 03/25/2022, which MAR shows an X for not due. This medication was issued in March 2022 as R1's MAR for December 2021, January 2022, and February 2022 did not have an order for this medication. According to the primary care physician's (PCPs) order there was an order change for this medication on 03/24/2022 from taking one tablet in the morning to taking one tablet every eight hours as needed. This was reflected on the MARs routine med order, and not to exceed 4 grams per day from all sources. This medication reflected on the PRN medications list as being administered a second time that started March 15, 2022, but did not exceed the dosage allowed. In further review of R1s, MAR, there was one other medication that was incorrectly discontinued. The medication was discontinued prior to the discontinuation date. The medication was not administered on 3/03/22 – 03/05/22 and was marked as discontinued on 3/05/2024 on the MAR. According to the annotation on the order it showed that the discontinuation date was on 3/04/2022. According to the Discontinuation orders, the discontinuation date is 03/04/2022. It was additionally said that the medications were being provide incorrectly to residents and there were medications that were missed for residents on/or around September 2022. In review of randomly selected residents MARs for September 2022 they indicated that there were discrepancies that the facility annotated for many medications unable to verify the medications and the medications were not administered. Although there were no annotations indicating the incorrect medications were provided to a resident on the MAR, there is information regarding the medications that were missed. (Continuation on LIC9099-C) (Continuation of LIC9099-C) According to R1s MAR, it showed that there were 11 medications that were not administered in September 2022 and in the back of the MAR it shows that staff did not administer mainly due to unable to verify. In review of resident #2 (R2) records for September 2022, there were four medications that were not administered due to unable to verify. In review of the records for resident #3 (R3), there were three medications and one essential oil that were not administered from the routine medication order due to unable to verify. In review of resident #4’s (R4) MAR for September 2022, they did not administer 10 medications on multiple days throughout the month due to mainly refusal or unable to verify. In review of the resident #4’s (R4) MAR it reflects that there were 11 medications that were not administered and according to the notes in the back was due to unable to verify. Upon further review of the MARs for the five residents during the month of March 2023 residents had multiple medications that were not administered due to inability to verify, blank notes, inability to locate, and pending refill or PCP approval for over half of one month’s worth of medications. Lastly, it was said that the medications were not being administered on time for residents who are insulin dependent and for pain management. Upon review of the current residents, R1, R2, R3, R4, and R5 they all had regular diets and no diagnosis of being insulin dependent. In review of the MAR’s they do not have timeframes the medications are administered unless they are a PRN. According to R4’s MAR they missed one of their medications due to inability of the facility to obtain the medication timely. At the beginning of the month, the medication was pending refill. Then the medication was later pending authorization, then the medication showed as being held towards the end of the month by the PCP which went back and forth. At the end of the month the footnote would indicate that the medication was refused, or the medication could not be verified. Interview with outside source statements conflicted. An outside source did not recall their time at the facility. Another outside source said that they did not recall any missed medications or medications not being provided to residents as prescribed by their PCP but recalled that the facility had outside agencies assisting as there was not enough staff. Another outside source and staff mentioned that they did not recall any medications not being provided to a resident as prescribed. (Continuation on LIC9099-C) (Continuation on LIC9099-C) There were staff who confirmed there had been medication errors and one that occurred about one year ago. According to staff interviewed the medication errors are reported to the charge nurse who then is responsible to ensure that the resident is monitored for 72 hours and responsible to make the proper notifications. Residents said that they walk to the Wellness Center for their AM and PM medications and the night medications are taken to their rooms. Executive Director confirmed that night medications are taken to the residents. Based on the information obtained there is sufficient evidence to support the allegation. Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff, resident and outside sources interviews, and review of pertinent records, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Executive Director Tracy Knepple. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to Executive Director Tracy Knepple at the conclusion of the visit. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, May 31, 2024 · control 08-AS-20220330150813

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(d) · Plan of correction due date: Jun 28, 2024

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration… this requirement was not met as evidenced by: Based on interviews and records review, the staff did not assist R1 with self-administration of a medications as prescribed. This posed a potential health risk to 5 of 150 of residents in care.the state’s words, verbatim · CDSS document, May 31, 2024

Plan of correction: Director of Resident Care Services will provide in-service training to med techs and nursing staff regarding proper medication administration and follow-up on pending orders and submit in-service training sheets to LPA by POC due date, 06/28/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(B) · Plan of correction due date: Jun 14, 2024

87303 Maintenance and Operation (i)(1)(B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff… this requirement was not met as evidenced by: Based on interviews, records review and LPA observations, the facility did not comply with the section cited above as the residents call signal was inoperable which posed a potential safety risk to 1 of 150 residents in care.the state’s words, verbatim · CDSS document, May 31, 2024

Plan of correction: Cleared on site as the signal system was fixed in 2022.

Allegation investigated: Resident sustained fall due to lack of supervision. Staff did not meet the residents assessed needs. Care staff did not have required training.

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced complaint investigation visit. LPA Silveira introduced themselves, met with Executive Director Tracy Knepple and disclosed the purpose of the visit. The purpose of the visit was to deliver complaint findings for the above-mentioned allegations. The Department’s investigation consisted of interviews with staff, residents and outside sources, as well as a facility records review. It was alleged that a Resident #1 (R1), who required assistance while toileting, was left alone in the bathroom by care staff in October 2021 and fell. A review of R1’s assessment records revealed that for October 2021, there was no fall registered for that month. Department interviews with residents who have lived at the facility since October 2021 demonstrated that residents had no concerns over staff not attending to their care needs. Interviews with care staff who worked during October 2021 revealed that there was no recollection of R1 having fallen during that month. Interviews with outside sources also revealed that there was no concern regarding resident’s care needs not being met. There was insufficient evidence to support this allegation. (CONTINUED ON NEXT PAGE, LIC 9099-C) Unsubstantiated (CONTINUED FROM LIC 9099) It was also alleged that R1 was not assisted out of bed in time for breakfast on 01/01/22 due to a lack of care staff being present at the facility. It was alleged that the facility did not have the appropriate number of care staff needed to meet residents’ care needs. A review of R1’s Physician’s Report and Department interviews with care staff who worked on 01/01/2022 revealed that R1 was able to use the call button when assistance was needed and was able to advocate for their own needs. An interview with an outside source revealed that R1 did not call for assistance on that day. An interview with the Executive Director regarding R1’s care needs revealed that sometimes, R1 was not interested in getting out of bed early and preferred to stay in bed and eat at lunchtime. Interviews with staff, residents and outside sources also revealed that there was no concern with the facility having a lack of staff on that date and during the month of January 2022. Interviews with the previous Executive Director, staff and outside sources also revealed that due to COVID-19 infection control protocols, staff were required to be sent home if they had symptoms or were sick during January 2022. The interviews revealed that while this caused an impact on care staff availability, it was not due to negligence and Agency staff were hired to fill in when needed. There was insufficient evidence to support this allegation. Lastly, it was alleged that Care staff did not have required training from October 2021 to January 2022. Department interviews with residents who had resided at the facility during that period revealed that there was no concern regarding staff not being properly trained. Interviews with outside sources also revealed that there was no concern regarding a lack of training for care staff during that period of time. Outside sources also expressed that they were content with care staff services towards residents at the facility. A records review of training records for some of the care staff who worked during that timeframe revealed that staff had completed the required training. There was insufficient evidence to support this allegation. Due to a lack of corroborating evidence, the allegations that a resident sustained a fall due to lack of supervision, that staff did not meet the residents assessed needs and that care staff did not have required training are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations occurred, therefore the allegations are unsubstantiated. LPA Silveira conducted an exit interview with Tracy. At the time of the exit interview Tracy was provided with a copy of the Complaint Investigation Report (LIC9099) and Licensee Rights (LIC9058 03/22). The signature on this report acknowledges receipt of the rights.the state’s words, verbatim · CDSS document, May 31, 2024 · control 08-AS-20220120172307

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management- Incident visit. LPa met with Executive Director, Tracy Knepple and discussed the purpose of the visit. The facility reported a timely incident involving Resident #1 (R1) that occurred on 03/09/24. The report indicated Staff #1 (S1) allegedly abused R1. S1 was suspended for approximately 1 (one) week pending the facility's investigation. R1 has a Major Neurocognitive Disorder and was unable to recall the incident. The facility assessed the resident and no injuries were sustained. The facility followed protocols and no deficiencies were issued. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Mar 28, 2024

Type of visit: POC

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced Plan of Correction visit. LPA met with Executive Director, Tracy Knepple and discussed the purpose of the visit. On 02/22/24, the facility was issued a deficiency for the facility being disrepair, regarding an air conditioning unit having a leak. The Executive Director had the air conditioning unit replaced. Today, LPA observed the air conditioning unit has been replaced and the deficiency has been corrected. No deficiencies were observed. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Mar 28, 2024

Type of visit: Case Management - Incident

LPA Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Tracy Knepple and Director of Resident Care Keisha Bean. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 02/15/2024). According to the LIC624: during the morning of 02/07/2024, an error by Staff #1 (S1) led to Resident #1 (R1) receiving doses of multiple medications which were not prescribed to them. These medications were instead prescribed to Resident #2 (R2). [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying that they were safe. LPA collected copies of and reviewed pertinent care records, training records, and physician correspondence. LPA also interviewed relevant staff. According to their latest LIC602 Physician’s Report (dated 06/30/2022), R1 was diagnosed with Mild Cognitive Impairment (MCI) and required staff assistance with taking their prescribed medications. Due to their baseline memory loss, R1 confirmed they felt well today, but was unable to recall the incident. Staff interviews aligned to show: On the morning of 02/07/2024, S1 was a newer employee undergoing medication pass training with a nurse manager. The nurse manager briefly stepped away to tend to another resident. Around 9:00 AM, Staff #2 (S2) had prepared a cup with medications for R2 and labeled it with R2’s name. S1 sought to assist S2 with their duties but confused/mistook R1 for R2. S1 did not ask R1 to verify their identity, and incorrectly handed this cup of pills to them. R1 then ingested four (4) medications which were not prescribed to them. Staff quickly recognized the error and timely notified R1’s primary care physician (PCP). [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Interviews, corroborated by faxed correspondence and date and timestamped progress notes, showed: The PCP provided written orders for staff to continue to monitor R1 at the facility and specified the circumstances / symptom triggers under which R1 would need to be sent to the hospital. R1 vomited later that same morning after eating a meal, but said they felt better after. R1 did not experience changes in their breathing or mentation. R1 did not exhibit the symptom triggers specified by the PCP to warrant 911. Staff measured R1’s blood pressure multiple times, finding it was consistently within a safe range. Staff continued to closely observe R1 for the remainder of the day and R1 returned to their baseline condition without the need for hospital treatment. Per manager interview and R2’s Medication Administration Record (MAR), the medication errors which affected R1 on morning of 02/07/2024 did not prevent R2 from receiving their respective prescribed medications on that date. Personnel records showed that Licensee provided one-on-one remedial medication pass training to S1 following the incident. A preponderance of evidence exists to show: During the incident in question, License’s staff (S1) did not give R1 medications as they were prescribed. The incident caused R1 to vomit but did not result in serious illness to R1. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Licensee. LPA also issued one (1) Technical Violation (TV) regarding reporting requirements. An exit interview was conducted with Knepple and Bean, to whom a copy of this report, the LIC 809-D, the LIC9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Feb 29, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 29, 2024

87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee’s staff did not assist 1 of 152 residents (R1) with self-administered medications as needed/prescribed, which posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: Manager interview and personnel records showed: On 02/20/2024, facility management met with S1 to perform remedial training regarding medication assistance. Licensee agreed to also perform retraining with its larger LVN/Med Tech team on medication pass procedures, and to submit the training sign-in sheet to LPA, by the POC due date.

Allegation investigated: Facility is in disrepair

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to commence a complaint investigation. LPA identified herself and discussed the allegation mentioned above with Executive Director, Tracy Knepple. During today's visit, LPA briefly toured the facility, requested records, and interviewed staff. It was alleged the facility was in disrepair due to Room #102 having a water leak coming from the air conditioning unit. It was reported the room was flooded at one point and towels were being used to absorb the water. Executive Director stated the leak was reported on 02/13/24. On 02/14/24, the Building Engineer took apart the air condition unit and located a clogged drain that was causing the leak and it was resolved that day. The Building Engineer confirmed the drains were clogged from the rain creating debris. The debris was cleared away and no more leaks were observed. Today, LPA observed a small puddle of water on the floor near the corner of the air conditioning unit. LPA also observed multiple rooms and no other leaks or water was observed in resident rooms. The Building Engineer will repair the leak tomorrow. Continued on an LIC 9099C. Substantiated Further outside source interviews revealed towels were still being used on 02/18/24 to absorb the water on the floor. Staff interviews confirmed there was water on the floor and towels were used to absorb the water. However, the resident located in that room gets up for the day and stays in the common area most of day, which also reduced a possible tripping hazard. Today, LPA observed a small puddle of water on the floor near the corner of the air conditioning unit, which was not a tripping hazard. LPA observed the environment was safe for the resident. LPA also observed multiple rooms to ensure residents safety. No other leaks or water was observed in resident rooms. The Building Engineer will repair the leak tomorrow. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights. Based on LPA’s observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Feb 22, 2024 · control 08-AS-20240221125035

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303 · Plan of correction due date: Mar 21, 2024

Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not ensure the facility was in good repair for 1 out of 149 residents [R1], which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Executive Director stated the leak will be repaired by POC due date.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident visit. LPA met with Executive Director, Tracy Knepple. The facility self reported an incident that occurred on 12/01/23 involving Resident #1 (R1). The report stated R1 was observed with injuries and R1 was unable to explain what happened. R1 was transported to the hospital for evaluation and returned the same day back to the facility with no new orders Today, LPA reviewed records and interviewed staff and R1. There were no indications of a violation. No deficiencies were observed today. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Dec 29, 2023

Allegation investigated: -Lack of supervision resulting in resident wandering from the facility -Staff did not treat resident with dignity -Staff can’t communicate with residents due to language barrier -Staff mismanaged residents’ medication -Staff did not meet resident’s medical needs

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the investigation regarding the above mentioned allegations. LPA met with Executive Director, Tracy Knepple. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged lack of supervision resulting in Resident #1 (R1) wandering from the facility. R1’s Physician's Report dated 06/15/23 indicated R1 had a Major Neurocognitive Disorder, confusion, wandering behavior, able to follow instructions, and was not allowed to leave the facility unassisted. R1 resided in the secured memory care unit with delayed egress doors. The delayed egress doors have signs that state “Push and hold for 15 sec. Alarm will sound door will open in 15 seconds.” R1 would read the sign, push, and hold, and once the door opened, R1 exited. Staff interviews confirmed R1 would read the sign and follow the directions then exit. There were two occasions 08/13/23 and 08/17/23, when R1 exited the delayed egress doors and walked out of the facility. Continued on an LIC 9099C. Unsubstantiated On both occasions, staff were present with R1 and had line of sight supervision. As staff were following R1, they stayed on the phone with the manager in charge providing details and location. Staff interviews confirmed R1 was safe with staff and did not sustain any injuries. Staff also confirmed they never lost sight of supervision with R1. Evidence obtained revealed there was no lack of supervision, as staff were present with R1 the entire time R1 was out of the facility and in the community. It was also alleged staff did not treat R1 with dignity. Outside source interviews revealed staff were rude to R1 by telling R1 to get back in their room and close the door. Staff interviews revealed R1 had family visiting frequently with small dogs that were not leashed. Therefore, staff asked R1 to go back into their room and close the door. Staff explained being worried about the other resident’s safety because the residents could trip on the small dogs or their leashes, plus some feared dogs. Resident interviews confirmed they were treated with dignity by staff. It was also alleged staff can’t communicate with residents due to a language barrier. Outside sources reported some staff do not speak English. Staff interviews revealed there were no language barriers, as all staff spoke English. The Human Resources Generalist explained speaking English is a requirement for the job. Therefore, all staff speak English. Additional outside source interviews confirmed there was no language barriers with staff and have been able to discuss resident care needs. Resident interviews confirmed they understand staff and there were no language barriers. It was also alleged staff mismanaged residents’ medication. Outside sources reported Resident #2 (R2) shared the same first name as R1 and R2 was given R1’s medications. Outside source interviews revealed staff were asked to review medications with outside source. During the review, the staff member accidentally pulled the medication for R2 and showed them to the outside source. The medication was not dispensed, only reviewed. The outside source confirmed no medications were dispensed or administered to either resident, as it was just a review. Staff also confirmed there were no medication errors involving either resident with the shared first name. Continued on an LIC 9099C. Lastly, it was alleged staff did not meet resident’s medical needs. It was reported there was an order on file to check R1’s blood sugar levels and ensure R1 used their CPAP machine at night. However, the orders were not being followed. A review of R1’s Medication Administrator Record indicated R1 was receiving blood sugar checks as prescribed. The facility did not have an order on file for a CPAP machine for R1. Some staff interviews revealed not being aware of the CPAP machine and unable to assist with CPAP machine as they were not trained. Other staff observed the CPAP machine in R1’s room but never noted it in use or an order on file. Further staff interviews revealed there was a discussion with R1’s family that an order would be needed but they never brought the machine or order. R1’s records did not indicate the need or use for a CPAP machine. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1 and Resident #2]the state’s words, verbatim · CDSS document, Oct 20, 2023 · control 08-AS-20230821160039

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Health Checks visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Tracy Knepple. During today's visit, LPA briefly toured the facility, performed a health and safety welfare check on residents in care, and spoke with staff. No deficiencies were observed or cited on this date. An exit interview was conducted with Knepple, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Sep 28, 2023