Carnelian I

Type of visit: Required - 1 Year

On 06/12/2026, at 09:00 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct this Annual inspection. Upon entry, the LPA stated the purpose of the visit to Resident Care Coordinator Ruby Bowers. The Administrator (ADM) Katherine Dunphy arrived at approximately 09:45 AM. The LPA toured the interior and exterior of the facility with the ADM. The tour of the facility included, but was not limited to, residents’ rooms, bathrooms, the central kitchen, and common areas. The LPA observed adequate lighting for the comfort and safety of residents throughout the community and in individual's rooms. The walkways in both the interior and exterior of the facility are free from obstructions. There are no bodies of water. The temperature of the refrigerators was below 40 degrees Fahrenheit and the freezers below 0 degrees Fahrenheit. At 11:01 AM, the living room temperature was measured at 72.3 degrees Fahrenheit. At 11:04 AM, the maximum hot water temperature was 118.5 degrees Fahrenheit in the shared bathroom. The residents’ bathrooms are equipped with grab bars and slip-resistant mats. There is more than the required minimum 7-day supply of nonperishable foods and a 2-day supply of perishable foods. The LPA observed the required postings in the facility. The smoke and carbon monoxide detectors were last tested on 10/02/2025 by Cintas and found to be in full operating condition. The fire extinguishers were last serviced on 02/24/2026. The Emergency Disaster Plan was reviewed by Administrator Adlai Grutas on 05/14/2026. Emergency and disaster drills are conducted quarterly; the most recent was conducted on 05/28/2026. The first aid kit was observed to be complete and staff dispense medications directly from the original container to residents. The liability insurance expires on 08/15/2026. An administrator is on site more than the minimum of 20 hours a week to ensure proper business operations are being conducted. Continued on LIC 809-C . . . . . . Continued from LIC 809 The LPA reviewed 5 Resident, 5 Staff, and the Facility records. No citations were issued for deficiencies during this inspection. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 12, 2026

Allegation investigated: Staff handled resident in a rough manner causing fracture.

On 01/23/2026, at 8:30 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to deliver findings on the allegation above. The LPA informed MedTech Gemma James of the reason for the visit. The Department's investigation included, but was not limited to, interviews with staff and a review of the records pertaining to Resident R1, which included facility records and medical records. The Department also inspected the facility, interviewed staff, and reviewed facility video recordings containing Resident R1. The complaint alleges that staff handled R1 in a rough manner causing a fracture. R1 is a resident who relies on staff for all activities of daily living. On 10/10/2025, R1 was taken to the emergency department by her daughter due to right arm pain and swelling. The X-ray showed a “spirally oriented fracture of the distal shaft of the ulna” with degenerative changes. The emergency department physician noted that spiral fractures typically occur with pulling or twisting of the arm. Continued on LIC 9099-C . . . Unsubstantiated . . . Continued from LIC 9099 On 10/15/2025, a physician specializing in orthopedics examined R1 and reviewed X-rays that revealed a minimally displaced long oblique/spiral fracture of the distal ulnar shaft. The specialist explained that such fractures are usually caused by direct impact, though twisting could not be ruled out. He stated that the injury was not a major cause of concern for possible abuse and appeared instead to be a "common" type of injury due to R1's osteoporosis. This was because R1 had osteoporosis, and the injury could have occurred if she hit her arm on something, or if her arm was caught in the hospital bed and R1 twisted her arm in an attempt to “get free” from the hospital bed. The daughter reported she has never observed staff handling R1 in a rough manner. Staff interviewed stated they always assist R1 by supporting her under the armpits during transfers from bed to wheelchair and have never pulled her arms. The resident’s room is equipped with a motion sensor and a bed alarm that alerts caregivers when R1 attempts to get out of bed, and caregivers have not witnessed any falls. In October, R1 began sleeping in a hospital bed with safety rails. On one occasion, staff observed that her arm appeared to be stuck in the bed rails, as if she had “tangled herself” in the safety railings of her bed. No further issues with the bed railings have been observed since then. According to interviews, review of facility records and video tapes, and a review of R1’s medical records, there was no indication that R1 was handled in a rough manner by staff causing a fracture. The data analyzed does not support the allegation. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 23, 2026 · control 15-AS-20251013102712

Type of visit: Case Management - Other

On 8/29/2025, at 9:00 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct this Case Management visit to the facility. Upon arrival, LPA stated the purpose of the visit to Caregiver Beth Panelo and Administrator (ADM) Katherine Grutas Dunphy by phone. The ADM arrived at the facility at approximately 10:00 AM. The LPA interviewed the ADM about food preparation and the shared dining areas in the three facilities. The ADM stated that a single kitchen in Carnelian I serving all residents and a shared dining room used as a multipurpose room has been the standard operating procedure since the facility was first opened in 1973. The LPA toured Carnelian I, II, and III with the ADM, inspecting the kitchen in Carnelian I, food storage in the shed, the dining areas in all three facilities, as well as the grounds of the facility. The LPA observed that more than the required minimum of 7 days of nonperishable and 2 days of perishable foods were securely and safely stored. The dining rooms were part of an open space that was centrally located in each of the three facilities, serving serve as multipurpose areas. Upon arrival, in Carnelian I, the LPA observed residents interacting with each other and their visitors near the entrance into the facility, while in the middle, in the dining room area, a few residents were eating and chatting with each other. Beyond the dining room, near the piano, more residents and visitors were talking with each other. In Carnelian III, a resident was being served food by a caregiver. Upon return to Carnelian I at approximately 11:00 AM, the LPA observed 14 residents sharing a live musical performance at the piano. No citation was issued during the inspection. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 29, 2025

Type of visit: Required - 1 Year

On 5/19/2025, at 9:00 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct the Required Annual Inspection of the facility. Upon arrival, LPA stated the purpose of the visit to Administrator Jay Grutas. The LPA toured the interior and exterior of the facility, inspecting the kitchen, food and emergency supply storage areas, dining area, shared restrooms, community living spaces, client rooms, and the grounds of the facility. More than the required minimum of 7 days of nonperishable and 2 days of perishable foods were appropriately stored. The maximum hot water temperature and the room temperature in the common areas were within the acceptable temperature range. The carbon monoxide and smoke detectors were fully operational. The fire extinguishers were last serviced on 3/31/2025. The LPA observed postings in the facility that included a complaint poster, Ombudsman, and Personal Rights posters. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations. The LPA reviewed facility records, records of 5 staff members, and records of 5 residents. No citation was issued during the inspection. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 19, 2025

Type of visit: Required - 1 Year

On 5/24/2024 at 10:00 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPA stated the purpose of the visit to staff members. Administrator (ADM) Katherine Grutas arrived at approximately 11:15 AM. The LPA inspected the interior and exterior of the facility with the ADM. The inspection of the physical plant included the kitchen, dining area, restrooms, community living spaces, resident rooms, storage areas, and the grounds of the facility. More than the required minimum of 7 days of nonperishable and 2 days of perishable foods were appropriately stored. Temperature in the living room was measured at 72.5 degrees Fahrenheit at 12:45 PM. The fire extinguishers were fully charged and last serviced 3/14/2024. The carbon monoxide and smoke detectors were fully operational. The LPA observed postings in the facility that included a complaint poster, Ombudsman and Personal Rights posters, Theft and Loss Policy, Rights to Resident Council, and Rights to Family Council. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations. The LPA reviewed facility records, records of 5 residents, and records of 5 staff members. The LPA interviewed 2 staff members and 2 residents. No citations issued during the inspection. Exit interview conducted with ADM and a copy of this report provided.the state’s words, verbatim · CDSS document, May 24, 2024