Citrus Heights Terrace

Allegation investigated: Staff are not ensuring that the facility is free of pests Staff are mishandling residents’ medication

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint received on-line anonymously on 11/15/23. LPA met with Ashley Stahl, Resident Care Coordinator (RCC) and explained purpose of inspection. Toni Jones, Administrator, was out of the facility during today's inspection. LPA observed several residents in the common areas during today's inspection. During today's inspection, LPA interviewed RCC and a Med-Tech staff and reviewed PRN medication for (3) residents, (R2, R3 and R4), as referenced in the complaint. LPA also toured the the room for resident (R1) who is also referenced in the complaint. LPA also observed and attempted to speak to several other residents who allegedly reported a rash and had complaints of itching. The results of the investigation are as follows: cont on 9099C-1... Unfounded 9099C-1... Allegation: Staff are not ensuring that the facility is free of pests. The complaint alleges that resident (R1) has roaches in her room. There is no day/time reference provided with the allegation. LPA and a Med-Tech staff (S1) toured (R1)'s room on 11/20/23. LPA observed (R1) to be sitting in a wheelchair and not able to speak clearly. LPA observed the carpet to be clean and did not see any roaches or other bugs in the room on the floor. LPA and the Med-Tech opened several dresser drawers in (R1)'s room, and there were no roaches observed. The Med-Tech stated that (R1) used to have a mini refrigerator in the room and would also eat near the refrigerator, and if there were any bugs in the room, they would be in the area where the refrigerator was. The Med-Tech staff stated she has worked all shifts and has not seen any roaches, or bugs, in (R1)'s room. RCC stated a family member has been moving resident's items from the room in preparation for a move and did not mention any sign of bugs. The complaint also alleges that residents (R1), (R4), (R5), (R6), (R7), (R8), (R9) and (R10), who reside in (7) different rooms, have rashes and complaints of itching. LPA reviewed the resident rooms provided with the RCC and Med-Tech (S1). The RCC stated that none of these residents have complained of a rash or itching in recent months and none of the residents had scabies a few months back. The Med-Tech staff stated that (R5) has not complained of a rash, and (R6) is under hospice care. The same staff stated (R4) uses skin creme on a regular basis as well as (R7) and (R1), (R8) and (R10) have had no rash. Resident (R9) who used to reside in a room that is currently vacant did not have a rash prior to passing. LPA was able to interview (R8) who indicated he has had no itching or rashes since moving to the community. LPA observed (R1) and (R4) in their rooms and did not see a visible rash. The other residents were not in their rooms at the time of the inspection and not able to be interviewed/observed. The Department previously investigated a similar allegation on 9/7/23 and had conducted a tour in the kitchen area, laundry area, staff break room and (2) resident dining rooms, including underneath the kitchen sinks, at that time. In all areas toured, there were no roaches or other bugs observed. Staff interviewed stated that the only roach seen was one trying to enter the resident dining room from the outside, and this was determined to be an isolated incident. LPA was provided with a invoice for service provided on 7/29/23, from an outside pest control company and confirmed that the facility receives regular scheduled pest control treatments. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. 9099C-2.. Allegation: Staff are mishandling residents’ medication. Complaint alleges that (R2, R3 and R4)) do not have a current supply of PRN medication for pain and agitation/anxiety. Complaint also alleges that there is loose medication in the common areas. LPA reviewed the PRN binder with documentation of the PRN and the Medication Administration Record (MAR) for November 2023. LPA and Med-Tech, (S1) reviewed PRN medications for (R2),(R3) and (R4), specifically, as follows: (R2)- documentation shows (R2) takes (3) medications for pain or agitation/anxiety- Acetaminophen, Ibuprofen and Lorazepam. LPA observed a bubble pack of Tylenol that was filled on 10/2/23 and had (25) of (30) tablets remaining. There were no tablets administered in November 2023. The facility received a discontinuance order for Ibuprofen and Lorazepam effective January 2023. RCC to update the PRN list and MAR. (R3) - documentation shows (R3) takes (1) medication for pain or agitation/anxiety- Trazadone 50 mg. LPA observed the bottle for the scheduled order and a bubble pack for the PRN. Resident has not requested or been administered any PRN for November 2023. (R4) -documentation shows (R4) takes (3) medications for pain or agitation/anxiety- Acetaminophen, Lorazepam and Morphine. (R4) is under hospice care. LPA observed a separate bottle for each of these medications on hand. November 2023 MAR shows there was no PRN medication administered for pain and or agitation/anxiety. LPA toured the interior of the facility and did not observe any loose medication in the common areas. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report emailed to the RCC.the state’s words, verbatim · CDSS document, Nov 20, 2023 · control 59-AS-20231115161701

Type of visit: Office

An informal conference was conducted at 1:00 pm on November 16, 2023, with Sacramento North Regional Office via Microsoft Teams. Present in the meeting was Licensing Program Manager (LPM) Maribeth Senty, Licensing Program Analyst (LPA) Sabrina Calzada, Licensee, Mark Cimino, Regional Director, Robert Godfrey, Quality Assurance Coordinator, Adina Nitu, and Administrator,Toni Jones. The purpose of this informal conference meeting is to address the facility’s compliance issues and substantiated allegations surrounding the numerous complaints received since May 2023. Specifically, the Department has concerns stemming from repeated violations following citations being issued. The licensee was told that this Informal conference is a part of the Administrative Action process and that further citations may result in an elevation to a formal non-compliance conference, which could lead to a referral to the Department's legal division for possible revocation of license. The following topics were covered during today's meeting: · Numerous complaints since May 2023- and the facility’s insight. · Substantiated allegations. · Repeated Substantiated allegations. · Steps taken to increase compliance- staffing changes, medication audits, facility processes, enrollment in the Department’s Technical Support Program (TSP) · Importance of training new staff. In an effort to support the facility in maintaining substantial compliance with the Health and Safety Statute and the Title 22 regulations, the Department is developing a plan with the licensee to address causes for concerns. cont on 809-C-1... 809C-1.. Licensee agreed to do the following: · Continue to conduct regular in-service training in response to any current areas of concern at the facility and with various medication topics. · Continue to conduct medication audits- both internally and externally and to follow audit recommendations. · Participate fully in the Department’s TSP engagement- focus areas: medication documentation and organization. · Ensure there are always adequate staffing levels to meet residents’ care needs and to increase staffing when appropriate, such as with an increase in census. · Submit any outstanding Plan of Corrections (i.e. October, November) No deficiencies were cited during today’s meeting. An copy of this report was provided via email to the Administrator with a request to return a signed copy to Community Care Licensing by COB 11/16/23.the state’s words, verbatim · CDSS document, Nov 16, 2023

Allegation investigated: Staff did not ensure resident's medication was ordered in a timely manner.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint received on-line anonymously on 11/6/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During today's inspection, LPA discussed the allegation with the Administrator, Resident Care Coordinator (RCC) and (1) Med-Tech staff. LPA reviewed Medication Administration Record (MAR) documentation for resident (R1) who is referenced in the complaint. The results are as follows: The complaint alleges that a family member of (R1) recently visited (R1) and asked staff the reason why she was not contacted when (R1's) medications ran out. cont on 9099C-1... Unfounded 9099C-1. Administrator stated that (R1) resides in a private room and her family has not visited recently, as one family member lives out of state and the other one lives outside of the local area. Both the Administrator and RCC confirmed there have not been any concerns recently brought to their attention from (R1's) family members, including with medications, and the Administrator stated she and (R1's) daughter discuss (R1's) care regularly. LPA reviewed MAR documentation for October 2023 and for November 2023 and observed there to be (8) medications listed. LPA observed documentation to be complete on the MAR and Centrally Stored Medication Record (LIC622), with the # of refills listed for each medication. A Med-Tech staff confirmed that she and other Med-Tech staff will call the pharmacy to request a refill and note it on the bubble pack as well as on the Fax transmittal. LPA observed notations on a bubble pack(s) that a refill had been ordered. Both the Administrator and Ombudsman were told by (R1's) daughter that neither she or the other family member filed this complaint. The Ombudsman spoke to (R1's) daughter on 11/8/23 who indicated she has no current concerns with medication administration but did in July 2023. The family member reported that all issues have been resolved, her mother receives appropriate care and all medications are ordered timely. Currently, the facility is participating in medication audits with multiple outside companies and has increased medication checks internally. Also mentioned in the complaint was that (R1) was not allowed to have a refrigerator. The Ombudsman and Administrator indicated that (R1) requested to have the refrigerator removed from her room a few months back due to the noise the motor made. Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Nov 9, 2023 · control 59-AS-20231106104515

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following receipt of an incident report. LPA met with Toni Jones, Administrator, and explained purpose of inspection. LPA and Administrator discussed the incident report submitted on 11/8/23 for a bed bug observed by a NOC shift staff on 11/6/23. After being informed, the Administrator immediately contacted a pest control company who conducted an inspection the same day and confirmed there were bugs in (R1's) bed, specifically in the air mattress delivered by the health care company around the end of September 2023. The pest control company also checked resident (R2's) side of the room and bed, and did not detect any bugs present. Neither (R1) or (R2) were observed to have any bug bites on them during the past weeks. LPA was provided with a copy of the invoice showing a volumetric heat treatment was performed on 11/7/23 in (R1) and (R2's) room. The invoice states occupants are required to remain outside of the area sprayed for at least (8) hours on the day of the service and a follow up inspection would be conducted. The Administrator stated residents remained out of the room during the treatment process and the health care company was contacted to inform of the situation, as well as local public health to report the bed bugs. LPA observed the Administrator to call the representative from the pest control company during today's inspection and confirm that a follow-up inspection will be conducted tomorrow, 11/10/23, in the afternoon. Administrator agrees to email documentation of the follow-up inspection. It appears this was a very isolated incident and the facility acted promptly and effectively upon discovering one bug. There are no deficiencies issued in this report. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Nov 9, 2023

Allegation investigated: Staff did not provide medical attention for residents in a timely manner. Staff do not ensure that residents have adequate toiletry supplies. Staff did not prevent an outbreak of scabies. Resident was left soiled for extended period of time. Staff not providing adequate food service to residents in care.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint received anonymously on 10/31/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During today's inspection, LPA discussed the allegation(s) with the Administrator, (3) caregiver staff, and (2) culinary staff. LPA interviewed (4) residents, including resident (R1), as best possible. LPA reviewed the visitor log for October 2023 and the Scabies Infection Line List provided to the county for (4) positive cases in October 2023. LPA also toured common areas and individual resident rooms. The results are as follows: Allegation: Staff did not provide medical attention for residents in a timely manner. The complaint alleges that a resident was heard screaming after falling in her room on 10/31/23, and staff left the resident on the floor after discovering she had fallen. The complainant provided a first name only for this resident. **cont on 9099C-1... Unfounded 9099C-1... The Administrator confirmed there is not currently a resident with this first name and described a recent incident when resident (R1), who has a similarly sounding first name, slid off her bed, which is low to the ground, and onto a fall mat, on 10/29/23, at approximately 2:50 pm. The Administrator stated (R1) will yell for staff if she needs assistance, and staff attended to (R1) immediately after she fell and did not observe any bruising or injuries at that time. The Administrator stated that staff sought immediate medical attention via triage over the phone with resident's health care provider, and it was determined that resident did not need any further medical intervention. LPA discussed the incident with (R1) on 11/1/23, who denied having a recent fall and couldn't confirm if she feels any pain. One staff who was interviewed stated "(R1) might have fallen two months ago" and was not aware of a recent fall indicating she is not currently assigned to care for (R1). Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff do not ensure that residents have adequate toiletry supplies. Complaint alleges there were no supplies such as wet wipes in (R1's) room to assist with incontinence care and also there is no soap/ body wash, toothbrush/tooth paste or lotion in (R1's) room. The Administrator stated that in the beginning of October 2023, she changed the type of disposable wipe staff use to provide incontinent care and showed LPA the dry wipe used previously that required staff to moisten it with a cleansing spray before each use. LPA also observed the pre-moistened wipes currently being used in green packaging. LPA spoke to staff who had just provided incontinent care to (R1). Staff confirmed that they always use wipes when providing care, as they are trained to do so and that they will use a caregiver cart with a bag containing wipes, gloves, and trash bag liners in it. LPA observed the carts with the bag hanging on the outside for easy access. (R1) indicated she receives assistance when needed from staff. LPA observed a package of green wipes in random resident rooms and staff indicated that hospice residents will also have wipes in the room for hospice staff to use. The Administrator stated the Maintenance Director is in the process of placing packages of wipes in each resident room. ***Cont on 9099C-2... 9099C-2...The Administrator stated that as a general rule, hygiene products are not kept unsecured in resident rooms or bathrooms, due to all residents having a diagnosis of Dementia, and that staff will regularly scan resident rooms for hygiene products hospice staff leave behind daily. LPA did not observe any hygiene products left out unsecured and within resident access. The Administrator confirmed that all hygiene products are kept either locked in the laundry area or in the resident drawer in the room with a clip lock. LPA observed that several resident's hygiene supplies are centrally stored for their safety. The Administrator confirmed that resident families will provide hygiene supplies to the facility. Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff did not prevent an outbreak of scabies.Complaint alleges the facility had a scabies outbreak and (2) resident names (R2 and R3) who share a room were provided. The Administrator provided LPA with a copy of the Scabies Infection Line List submitted to the county health department for (4) positive cases reported in October 2023. The Administrator confirmed that (R2) never tested positive for scabies, and (R3), who shares a room with (R2) did test positive. The Administrator confirmed all residents just started back attending their health care day program this week after a 2 week, 4 day postponement, and it is thought that the scabies was brought into the facility from contact at the day program. Additionally, there are no staff ever tested positive. The Administrator indicated she remains in weekly communication with public health for further monitoring through 11/30/23. This allegation was previously investigated and found to be UNFOUNDED on 8/18/23. Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Resident was left soiled for extended period of time.The complainant alleges they have observed facility staff not properly cleaning residents and not using wipes. All staff interviews confirmed that staff provide timely assistance when a resident needs incontinent care. LPA observed staff to be finishing up providing incontinent care to (R1) and to other residents during today's inspection. There is no information provided as to the specific resident(s) the allegation pertains to. LPA did not observe significant incontinent odors present when touring and observed multiple caregiving and Med-Tech staff present. Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. *cont on 9099C-3.. 9099C-3... Allegation: Staff not providing adequate food service to residents in care. The complaint alleges that (R1) has complained the food is not served on time and it is often cold. (R1) stated to LPA that when the food is cold, "I tell them it needs to be warmed". Staff interviews indicated that (R1) is served pureed food in her room and staff will hand feed her with a spoon. One staff stated "(R1) will always say the food is too cold, there is not enough flavor and it needs more sugar". LPA interviewed (2) culinary staff who indicated that food is served hot to residents if it's supposed to be hot. One staff stated "residents will complain if the soup is too hot, but we never get complaints about it being too cold", commenting, "maybe the caregivers don't serve it fast enough". One of the kitchen staff stated when preparing pureed food for (R1), she will take the food directly from the warm stove and place it in a blender. This staff stated that caregivers for (R1) will most often come to the kitchen to request sweets for (R1) more than for any other reason. Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. These allegations are being dismissed without any citations being issued. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Nov 1, 2023 · control 59-AS-20231031105239

Allegation investigated: Staff did not prevent resident from being sexually assaulted. Staff did not seek medical attention for resident in a timely manner. Staff are not providing resident's authorized representative with copies of incident reports

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver investigative findings to a a complaint received on 5/4/23. LPA met with Ashley Stahl, Resident Care Coordinator, and the explained reason for the inspection. The Administrator, Toni Jones, attended today's inspection by phone. During the investigation, LPA conducted interviews with multiple facility staff, (2) family members of resident (R1), (2) medical personnel, the Ombudsman and a law enforcement detective. LPA reviewed documentation for (R1) including, but not limited to, admission paperwork, physician's report, care plan, charting notes, and incident reports. LPA also reviewed documentation for resident (R2), which included police and 9-1-1 incident report from local fire. The results of the investigation are as follows: cont on 9099C-1.. Substantiated 9099C-1.. Staff did not prevent resident from being sexually assaulted. Complaint alleges that (R1) was sexually assaulted on 4/15/23 by another resident (R2) and that resident (R2) was no longer allowed at the facility due to previous behaviors. Staff interviews revealed that while doing rounds on 4/15/23, at approximately 5:00 am, (2) staff found (R2) laying naked on top of (R1) in (R1's) bed. Interviews confirmed that (R1) was observed to be wearing a diaper and a nightgown, and there was a third resident (R3) in the room sitting in a chair. Staff interviews revealed that (R3) was (R2’s) girlfriend and would walk around the facility together. The incident report submitted to the Department states that on 4/15/23, at approximately 7:00 am, (R2) was observed without clothes laying on top of (R1), who was fully clothed, and the residents were separated and (R2) was returned back to his room. The facility incident report notes law enforcement was notified and later came to the facility to investigate and (R2) was transferred to the hospital for further evaluation and had remained there as of 4/17/23 when the report was submitted. The report notes that (R2)'s conservator contacted facility staff on 4/17/23 to advise that (R2) would not be returning to the facility due to his behavior. Staff interviews confirmed that (R2) "was always up during the NOC shift", and would frequently try and exit to the patio courtyard as the alarms would go off and go in other resident rooms. Staff interviews revealed "(R2) always hit on different women from the start of NOC shift until breakfast time", with one staff stating, "I've seen him (R2) with other women- he was just laying there, cuddling". Staff interviews indicated that (R2) was "more physically aggressive”, would push other residents and hit them, and his behaviors were not taken seriously by the Administrator at the time, commenting (R2) was "sent out constantly but would return" and would walk around naked on a regular basis, taking (3-4) staff to get (R2) out of another resident's room. Resident (R2) moved to community in March 2020 with a diagnosis of Dementia, and other conditions and was conserved. (R2's) care plan, dated June 2022, says (R2) needs maximum assistance in redirection due to elopement risk and wandering throughout the building, in residents’ rooms and exit seeking during the day. The care plan also notes (R2) needs maximum assistance to maintain safe and appropriate interactions and due to severe sleep disturbances caused by sun downing. cont on 9099C-2.. 9009C-2... (R2's) Physician's Report, dated 2/22/23 states resident is confused, disoriented, has inappropriate behavior and is aggressive. Electronic charting notes entered by the Administrator and Resident Care Coordinator note that (R2) was showing an outburst and inappropriate behavior on 3/13/23, agitation and change in baseline on 3/15/23 and showed more agitation and a change in condition on 3/29/23. An updated LIC602 was obtained on 3/27/23 noting resident is confused, disoriented, shows aggressive/wandering/sun downing behavior and inappropriate behavior, has bladder impairment, and is now not able to feed himself or do any Activities of Daily Living (ADL's). The Ombudsman investigated the incident and contacted the police department for their report and concluded that the case did not meet criteria for a criminal case due to (R2) having a diagnosis of Dementia and suffering a stroke (3) weeks prior causing him to be more aggressive. The police report based their findings on the Ombudsman's findings. LPA reviewed a copy of a fire (911) incident report, dated 4/15/23, noting facility staff reported (R2's) behavior to be of concern for the safety of other residents as (R2) attempted to interact inappropriately with other residents in addition to (R1). On 4/16/23, (R2) was sent to the Emergency Room for a mental evaluation and was placed on hold due to his pattern of behavior within the community and did not return to the facility. LPA conducted a case management inspection on 4/21/23, after receiving the incident report on 4/17/23. LPA attempted to speak to resident (R1) in the presence of Administrator, but resident was not able to speak and be understood but was in a pleasant mood. LPA did not observe (R1) to show any bruises on her face or lower legs that were not covered by clothing. LPA observed (R1) able to move herself in a wheelchair. The Administrator at the time did not discuss any concerns with the LPA regarding either resident (R1/R2) or mention that another resident (R4) had sustained an unexplained head injury during the same shift, was sent to the Emergency Room and received multiple staples on her head. Staff interviews and interviews with responsible persons for (R4) revealed that (R4) and (R2) may have entered into a altercation and (R4) was hit on the head or fell and hit her head. The incident report submitted for (R4) states that she was found on the floor in her room, at approximately 7:00 am, on 4/15/23, with blood on her head but could not recall how the injury happened. Discharge papers show (R4) was seen in the ER on 4/15/23 for head pain and was diagnosed with head trauma, laceration of head and UTI symptoms, and the laceration was treated with (4) staples. cont on 9099C-3.... 9099C-3.. One staff stated (R1) has "no way to consent since she is non-verbal" and she "can't defend herself". Another staff stated "(R1) mumbles and says phrases only" and would not have been able to consent to (R2) being in her bed. Two staff stated (R1) appeared “traumatized for sure”, (R1's) face had a different color and she had her head down after she and the other staff pulled (R2) off of (R1). Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff did not seek medical attention for resident in a timely manner. Complaint alleges that (R1) wasn’t examined following the incident on 4/15/23 until 4/20/23 when the facilitiy's Nurse Practitioner (NP) came to the facility. The responsible person for (R1) stated that when informed of the incident on 4/15/23, she asked facility staff if (R1) had been taken to the hospital to be checked out and was told she had not been. This family member stated she then demanded that (R1) get checked out, but (R1) wasn’t check out until 4/20/23 by the facilities NP. The family member stated on 6/10/23, she called the NP last week and left a message, but she had not heard back. Charting Incident notes for (R1) document the incident on 4/15/23 (Saturday) and on 4/16/23 notes state there were no changes observed for (R1); on 4/17/23, notes say NP was contacted and would be coming out to “check (R1)” and (R1) has been doing good and is still wandering around the facility. On 4/18/23 and 4/19/23, additional notes were entered that there were no changes. (R1) did not receive any medical attention until 4/20/23 when NP visited the community. Notes say: “NP checked (R1) from head to toe and all skin is good and there are no changes for (R1)”. The NP stated he believes (R1) was on hospice at the time, was frail, and could not provide any other information. A hospice nurse stated that the incident was never confirmed with him but (R1) was not under hospice care at the time. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. cont on 9099C-4... 9099C-4... Allegation: Staff are not providing resident's authorized representative with copies of incident reports. Complaint alleges (R1's) family member requested copies of all incident reports with (R1) and she hasn't received any reports. (R1's) family member stated that (R1) has gone to the Emergency Room 4-5 times in the last (8) years while living at the facility. The family member stated she spoke with a manager to request the reports, and the reports were not made available to her. LPA discussed this request with the current Administrator who indicated that this family member would reach out to the Administrator regarding why she is not currently not in contact with the facility. The current Administrator stated she has not heard from this family member for a while. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (3) citations are issued on the 9099-D pages. Exit interview. Copy of report and appeal rights provided. 9099A-C-1... LPA reviewed the incident report (LIC624) for an incident occurring on 2/11/22- at 10:30 am, when (R1) found on the floor during staff rounds. The LIC624 notes (R1) had no visible injuries but was sent to ER and had remained in the hospital as of 2/14/22, when the incident report was completed. The LIC624 notes this family member was notified. A second family member of (R1) indicated there were several incidences of (R1) having a fall and recently she fell last month in September twice, between Sept 6 and 10th. Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Resident had an unexplained fall sustaining injuries due to staff negligence. Complaint states that before (R1) fell and fractured her hip, she had another unexplained fall and staff do not know what happened. There are no other details provided. A LIC624 was submitted for an incident on 2/11/22- 10:30 am where (R1)found on the floor during rounds with out any visible injuries. (R1) was transported to the hospital and remained there through the time the LIC624 was submitted on 2/14/22- 3+days in the hospital. This person indicated that the assigned hospice nurse found (R1) when she fell in Feb 2022. One family member stated (R1) had some bruising on her face and would provide the Department with photos early in the investigation, but they were not provided. A second family member indicated there were several incidences of (R1) having a fall and recently fell last month twice in September, between Sept 6 and 10th. This family member stated that for the first fall, (R1) was sent to ER and released the same day for no injuries; however, the second time, (R1) fell in the lunch room and was by herself. This family member stated the facility thought it was a "harder fall" and had (R1) sent out to the Emergency Room for CT scans and additional tests , stating "they were more concerned about the second fall". cont on 9099A-C-2... 9099A-C-2... Allegation: Staff did not prevent a resident from engaging in inappropriate behaviors. Complaint alleges that when (R1’s) family member was visiting she heard (R1) screaming and observed another resident (unknown name) attacking her mom on the floor. One of (R1's) family members stated there was another time when (R1) "was attacked by another resident" around 2021-2022. This person stated that the nurse from hospice was there and he had called her due to (R1) having some bruising on her face. Photos were not provided to the Department as previously agreed to. The LIC624 submitted for the incident on 11/17/21 was completed 11/18/21 and involved (R1) and (R5). The incident report states that around 3:00 pm, staff heard (R1) shouting for help and went to assess the situation and found (R1) on the floor and (R5) was kicking (R1). Staff called for a shift manager and both staff were able to separate the residents. Both residents were sent to the ER and (R1) returned to the community with no changes. (R5) remained in the hospital as of when the report was completed on 11/18/21. A second family member confirmed that (R1) was on and off of hospice several times since moving to the facility in 2014 and that she had a lot of falls. This family member stated that (R1)would "walk and walk" prior to moving to the community and liked to be on her feet. Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided. 9099A2-C-1...One staff stated the incident with (R1) and (R2) was "reported the day after" and that they called (R1's) family and left a message for both family members who were alternating as POA's. This staff asserted "neither one answered", but "I know for a fact that I personally called both of them- they called back after my shift ended". Resident charting notes do not indicate that (R1’s) responsible person(s) was contacted immediately following the incident; however, the LIC624 (dated 4/17/23) states that residents’ responsible parties and primary care physician's were notified. The Administrator and RCC agreed to provide staff training on ensuring that notes are entered every time staff makes an attempt to contact the responsible person. Based on information obtained, LPA finds this allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Oct 26, 2023 · control 59-AS-20230504150756

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 27, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, 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 and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and documentation reviewed, the Licensee did not ensure that (R2) and (R1) were provided with sufficient supervision, on 4/15/23, during the NOC shift, to prevent him from entering (R1's) room and laying naked on (R1) while she was in bed, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 26, 2023

Plan of correction: Licensee/Administrator agree to conduct staff in-service training regarding sexual abuse and checking rooms, more regularly, throughout more shifts. Agenda to be received by 10/27/23- training documentation to be submitted by 11/9/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Oct 27, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) 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 record review and interviews, the Licensee did not ensure that (R1) received prompt medical attention, following the incident with (R2) on 4/15/23, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 26, 2023

Plan of correction: Licensee/Administrator agree to conduct an in-service training on when to call 9-1-1 and seek medical attention needed, Agenda to be received by 10/27/23- training documentation to be submitted by 11/9/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Nov 9, 2023

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on interviews conducted, the License did not ensure that (R1's) responsible person was provided with copies of incident reports when requested on/around May 2023, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 26, 2023

Plan of correction: Administrator agree to continue to submit LIC624's timely and to provide a copy to the responsible within (7) days of the incident. Administrator to discuss with Resident Care Coordinator and submit documentation to CCLD that this protocol has been discussed and will be regularly followed. Documentation to be submitted by 11/9/23 to CCLD. Administrator will attempt to contact responsible person of (R1) and send all LIC624's, as requested.

The state marks this report as 13 pages; the online copy we transcribed has 12. You can request the full file from the county licensing office.

Allegation investigated: Staff are mishandling resident's medications. Staff does not ensure resident is administered medications as prescribed. Staff leaves resident's mattress soiled. Resident's room is malodorous.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to close a complaint received on-line and anonymously on 07/26/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During the investigation, LPA discussed the allegations with the Administrator, RCC and a Med-Tech staff and toured the facility on several different occasions. LPA went into multiple resident rooms, including the room referenced in the complaint, and also checked several residents's bedding to see if it was soiled. The results are as follows: Allegation: Staff are mishandling resident's medications. The complaint alleges there were medications seen in resident’s room (shared by R1 and R2) when visiting one of the residents. *cont on 9099C-1... Unfounded 9099C-1...The room referenced in the complaint is occupied by (2) residents. LPA toured the room on 7/31/23, 8/22/23, 9/7/23 and 9/26/23 and did not observe any medications to be left out in the room. The complaint does not indicate which resident this allegation pertains to nor were there any specifics provided as to the day of the week, time of day, or name of medication. Based on information obtained during the investigation, LPA finds this allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff does not ensure resident is administered medications as prescribed. Complaint alleges that resident’s family member monitors resident’s medications and facility staff did not notify family member that the resident has been out of her meds for a couple of weeks, and resident'’s doctor was not notified either. The Department received additional anonymous on-line complaint on 7/27/23 alleging the same information. There were again no specifics provided. The Administrator, RCC and a Med-Tech (S2) stated on 10/24/23 there have been no problems with (R2) receiving her medications and indicated she has been on hospice for the majority of the time she has been a resident at the facility. The current Administrator and the RCC stated there was only a problem with (R1) receiving medications on/around March 2023 when the dispensing pharmacy sent medications to (R1's) prior residence. This allegation was investigated previously for (R1). There were no specifics provided as to which resident in the shared room the allegations pertain to. Also, the day of the week, time of day, and name of medication were not mentioned. Based on the lack of specific information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. cont on 9099-C-2... 9099C-3...Allegation: Staff leaves resident's mattress soiled. Complaint alleges that when visiting resident’s room, resident’s mattress is soiled with the urine, the mattress was even wet to the touch. On 7/27/23,the Ombudsman inspected the shared room and did not observe either resident's mattress to be soiled. On 7/31/23, LPA inspected both resident mattresses in the room and observed them to be dry. LPA observed layers on the plastic protector- 1- cloth, 2- sheet, 3- cotton chuck, 4- disposable chuck. (S1) indicated the caregivers have to help with changing sheets as housekeeping gets busy. (S1) confirmed that caregivers will make beds and replace any soiled sheets "right away". (S1) stated (R1's) daughter picks up her laundry every other day and wants to wash (R1's) sheets even if they are soiled.-(S1) commented that maybe once/week they are soiled and (R1's) daughter has never asked them not to separate the soiled sheets, and she has specifically told staff "don't wash the sheets" since the dryer shrinks them. Staff (S1) stated (R2) who also occupies the room is incontinent like 89% of the residents. (S1) stated all incontinent residents have both a cotton and disposable chuck on the sheets. 11% of residents can walk to the bathroom. LPA observed (R2’s) mattress and bedding to be clean and dry. LPA also toured (8) other resident rooms with care staff (S1) and observed all resident beds to have dry, clean sheets on them. LPA toured the shared room again on 8/22/23 with the Administrator. LPA observed (5) layers of protection on the top mattress and then a top sheet and (2) blankets. LPA observed all layers to be dry and appear to be freshly laundered free of any incontinent odors. LPA observed roommates' bed to also be dry in all layers. On 9/7/23, LPA confirmed with a housekeeping staff that she and caregivers change resident sheets, and there are not any female residents that stand out as having significant incontinent issues. This same information was confirmed with a second care giving staff also on 9/7/23. LPA toured the room again, on 9/26/23, with the Administrator. Both residents were outside of their room in the common areas during the inspection. LPA pulled the blankets back to observe the bedding on each resident's bed. LPA observed all bedding, including Chux pads, to be clean and dry and did not observe any urine stains. Based on information obtained during the investigation, LPA finds this allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. cont on 90099C-... 4 9099C-4... Allegation: Resident's room is malodorous. Complaint alleges that when visiting resident’s room, resident’s room smelled like urine again. On 7/27/23,the Ombudsman inspected the shared room and did not observe any smell of urine. On 7/31/23, LPA did not observe any incontinent odors in the shared room for R1 and R2. LPA also toured (8) other resident rooms with care staff (S1) and did not observe any significant incontinent odors in the rooms toured. LPA toured the shared room again on 8/22/23 with the Administrator. LPA observed the room to be neat, bed made and without any incontinent odors and to contain lots of incontinent supplies in the bathroom. There were no incontinent odors present. On 9/7/23, LPA toured (3) additional resident rooms that were observed to be clean, without any significant incontinent odors, and the trash was emptied. LPA also observed residents’ beds to be made. On 9/26/23, LPA observed the shared room and bathroom to be clean and odor free. Based on information obtained during the investigation, LPA finds this allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. There are no deficiencies issued on this report. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Oct 24, 2023 · control 59-AS-20230726152403

Allegation investigated: Staff are mishandling the residents medications Staff have inadequate records keeping for the residents medications Staff have not repaired the pull cord system in the facility

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open and close a complaint received anonymously on-line on 10/17/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During today's inspection, LPA discussed the allegation(s) with the Administrator, Resident Care Coordinator (RCC) and the Maintenance Director. LPA, RCC and (1) Med-Tech staff reviewed medications for (5) residents whose room numbers were referenced in the complaint and also tested random resident pull cords in individual bathrooms. The results are as follows: Allegation: Staff are mishandling the residents medications. Complaint alleges that medications have been out for a month for residents who occupy (4) specific rooms. The Narc count is off and is not accurate Norco and lorazepam is off *cont on 9099C-1... Unfounded 9099C -1... LPA, RCC and a Med-Tech staff reviewed medications for (5) residents who occupy (4) rooms mentioned in the complaint. All medications for (R1) were on hand except for the medication, Lactulose 10/15 g/ml that ran out yesterday. RCC stated that this medication is ordered by hospice and (R1) refuses medications daily and hospice is aware. RCC stated that this medication has a pending discontinuance order. All medications were on hand for (R2. Medications were reviewed for (R3). All medications listed on the most recent physician's orders (Sept 2023) were found to be on hand and are being administered per the orders There were (3) prior medications that (R3) was prescribed from when she was in the hospital. RCC stated these (3) medications were not taken since (R3) returned from the hospital and have been discontinued. RCC is trying to get approval for (R3) to begin Home Heath. Medications for (R4) and (R5) were reviewed and found to be on hand and are being administered currently. LPA observed all documentation on the Medication Administration Record (MAR) and Centrally Stored Medication Record to be current and legible. LPA, Administrator, RCC and (1) Med-Tech staff conducted a narcotic count for (3) randomly selected residents. The count matched the number written on the Narcotic Documentation page for all (3) residents (R6, R7 and R8). Based on review of medications and medication counts, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff have inadequate records keeping for the residents medications. The complaint alleges the central stored binder is a mess. LPA reviewed the Centrally Stored Medication Binders and observed it to be organized with tab dividers. The pages (LIC622) were completed by hand and filed with the more recently logged medications first. LPA observed a few loose, torn pages in each binder, but the binder overall was very neat and organized. LPA discussed ways with the Administrator to possibly eliminate staff having to write the same information repeatedly for the same medications on the LIC622. cont on 9099C-2... 9099C-2... LPA also reviewed the Centrally Stored Narcotic Binder which was recently created by the RCC. The binder was also organized with tab dividers by each resident room. LPA also reviewed the Narcotic counts and observed (1) entry for each shift change and (2) signatures to have been written on most days, after each narcotic count. The Administrator stated that sometimes when a staff works a double shift, she or the RCC acts as the second staff who counted the narcotics. The facility was cited recently for not documenting completely for PRN medication specifically. Ongoing training is being done regarding proper documentation for medications. Based on documentation review, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff have not repaired the pull cord system in the facility. Allegation states the pull cord system is not working with no specific details included. LPA, Administrator and RCC tested multiple (4) bathroom pull cords on 10/24/23. LPA observed each pull cord to light up when pressed and heard the RCC announce on the walky the Administrator was carrying that assistance was requested in the specific room. LPA also observed a staff member to arrive at the identified room promptly after the pull cord was pulled. LPA spoke to the Maintenance Director who confirmed that he and the Administrator check weekly to ensure the pull cords are working properly. The Administrator confirmed that the Maintenance Director will begin in room #101 and pull both the bathroom and resident pull cords and she will be watching the monitors in the RCC's office. The Administrator will then communicate with the Maintenance Director, using a separate walky to not interfere with staff's line during their testing process. The Director stated maybe 1-2 batteries are found to occasionally need replacement, but not on a regular basis. Based on documentation review, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. There are no deficiencies issued on this report. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 24, 2023 · control 59-AS-20231017114128

Allegation investigated: Staff was verbally abusive to a resident. Staff are not adequately supervising residents.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the investigation deliver findings to a complaint, received on 7/18/23, for the above allegations. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During the investigation, LPA interviewed the current Administrator, Resident Care Coordinator (RCC), (2) staff and (2) residents. LPA reviewed the incident report binder organized for months April -August 2023. The results of the investigation are as follows: Allegation: Staff was verbally abusive to a resident. The complaint alleges a family member witnessed staff being verbally mean to the residents. There is no date, time or resident names referenced for this allegation. One staff stated on 7/20/23 there is no verbal abuse ever but she will speak firmly with the residents since they have Dementia. A second staff who has worked at the community for many months stated he is not **cont on 9099C-1... Unfounded 9099C-1...aware of any staff speaking abusively to a resident and staff might need to speak firmly but would never speak harshly. A third staff indicated she has never heard any verbal abuse from staff towards residents. (2) residents were asked if they have ever observed staff to talk harshly or rudely to residents. Both residents stated that staff has never yelled, screamed, or used profanity with one resident stating staff is "very helpful, very nice and polite". LPA has never observed any staff to speak harshly or inappropriately to a resident when visiting the community on multiple occasions. Based on information obtained during the investigation, LPA finds this allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff are not adequately supervising residents. The complaint alleges a family member heard staff speaking to a manager on the phone about three seniors yelling, pushing and hitting one another and that when the residents fell to the ground, no management came to see if they were okay. Additional information was received on 7/20/23 alleging to be from a “concerned neighbor” that a male resident left the building again and went over the fence. On 7/25/23, additional information was received from an anonymous staff member reporting that a new resident left the building again and went to the nearby Mc Donald’s. The RCC stated on 7/20/23 that if she were to see (3) residents hitting and pushing she would send them out to the ER, and if the residents were yelling, she stated "they're going to yell - they have Dementia". RCC commented, "we're going to have agitated residents" since it's Memory Care. The current Administrator, who began working at the community in August 2023, stated that she has never observed (3) residents to be involved in the same altercation, and has only seen (2) to be involved. One staff stated she is not aware of (3) residents yelling, hitting and pushing one another, and that if she encounters an issue, she will speak to staff about it right away to correct it. Another staff stated that he doesn’t recall hearing about (3) residents yelling, pushing and hitting each other on/around July 2023 and confirmed that (R1) AWOL’d from the facility only once, the first night he was there, on 6/29//23. A third staff stated staff will respond instantly if there is a fall or altercation. cont on 9099C-2... 9099-C-2.LPA reviewed several months of incident reports that were submitted to the Department and did not see any subsequent AWOL incidents for (R1) or any other AWOL's for any other resident, which the Administrator confirmed to be correct. LPA also did not observe an incident report noting (3) residents were involved in the same incident. (2) residents indicated to LPA that staff will respond promptly if a resident falls or or is in a situation with another resident. Based on information obtained, LPA finds the above allegations to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 59-AS-20230718104900

Allegation investigated: Licensee is not following reporting requirements

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the investigation and deliver findings to a complaint, received on 7/18/23, for the above allegation. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During the investigation, LPA discussed the allegation with the current Administrator, Interim Administrator, Resident Care Coordinator (RCC), (4) staff and reviewed the Incident Binder. Administrator reviewed staff training on the computer and confirmed that all staff have completed coursework in Abuse, Neglect and Explotation in an Elder Care Setting and Resident Rights, Personal Rights and Ethics. Mandated reporting is discussed in these (3) courses. Allegation: Licensee is not following reporting requirement. The complaint alleges that a manager told staff last week not to report, and incidents are not being reported as required. There are no specifics included in the complaint and the complainant is anonymous. cont on 9099C-1.. Unfounded 9099C-1... The RCC stated on 7/20/23 that staff will call her if there is a serious incident and she will then let the Administrator know, who will review the incident reports and send them in. The Interim Administrator confirmed on 7/20/23 that she reviews the incident reports provided to her from staff before submitting them to the Department. The RCC stated on 10/17/23 that she has never disposed of incident reports given to her by staff and she talks about the importance of Mandated Reporting in staff meetings. Additionally, the RCC indicated that staff will complete "individual 1:1 training" in her office on the computer. LPA received information that a prior Administrator would sometimes tell staff not to report incidents to the Ombudsman, and to the Department, but that staff would still report since they are mandated reporters. This was prior to May 2023. The current Administrator stated that she was trained that the person observing the incident should be the one reporting and completing the incident report. She will review the report before sending it to the Department and has never seen any manager or staff rip up an incident report. The current Administrator indicated she will take the internal notes from the incident and write the incident report to be submitted to the Department. One staff stated on 10/16/23, that he and other staff were told at staff meetings that staff “should know what to report and to tell a lead, Med-Tech, staff, but if the incident is unwitnessed, staff can’t write a report if they have not witnessed the incident. A second staff interviewed stated she has never been told personally not to report incidents, has completed training on mandated reporting, and has been talked to in a group by managers. This same staff confirmed she only completes an incident report for what she personally observes and will ask a caregiver to complete a report if he/she has witnessed an incident and then provide that report to her. This same staff stated staff will place the completed incident report under the RCC and Administrator's door and has no way of knowing if the incident ever got reported. Two (2) additional staff stated that they have received training on being a mandated reporter, with one staff confirming she has completed incident reports before. The second staff stated she has observed incidents with other staff present and those staff have completed the incident report and included her name on it. All staff interviewed stated they would not listen if they were told not to report an incident since they are mandated reporters. LPA reviewed the incident binder and observed each month to contain copies of multiple incident reports submitted to the Department. Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 59-AS-20230718114857

Allegation investigated: Staff are falsifying residents' records. Staff are not providing residents activities of daily living (ADL's).

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the investigation and deliver findings to a complaint, received on 7/25/23, for the above allegations. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During the investigation, LPA interviewed the current Administrator, Resident Care Coordinator (RCC), (2) Med-Tech staff and (1) caregiver staff. LPA reviewed the Narcotic Shift Count log from April- August, 2023, and the Controlled Substance Record from January- August, 2023. LPA also reviewed the October shower log. The results of the investigation are as follows: Allegation: Staff are falsifying residents' records. The anonymous complaintant alleges the narcotic count was off, and he/she was told to correct it when it wasn't that staff that made the mistake. cont on 9099C-1... Unfounded 9099C-1... A Med-Tech staff stated that prior to May 2023, she was told to sign the narcotic log that the count was correct, even if it was off by one or two tablets. This staff stated the narcotic count could regularly be "off" by one or two tablets for a resident or two and that record keeping is much better now. The RCC stated that staff would tell her if the narcotic count was off and she would inform the prior Administrator who stated she would "look at it". LPA reviewed the Narcotic Shift Count documentation and observed it to be complete- and "none" was written in most spaces where any discrepancy is noted. There were no notes indicating the medication count was off. LPA reviewed the Controlled Substance Record where a date was entered when the medication was received and then each day it was administered. There were no noted errors based on the entries made on either documentation. There was no specific resident, medication or day/time referenced. Based on information obtained during the investigation, LPA finds this allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff are not providing residents activities of daily living (ADL's). The complaint alleges that staff is asked to correct the ADL binders as well because there are holes and shows that ADLs are not being done. A Med-Tech stated on 7/31/23 that everyday NOC shift will document when care is provided (i.e. incontinent checks) and will fill out logs only if there are issues or concerns, explaining that this is a new system that started a year ago. LPA asked this staff if the facility has enough staffing. This staff asserted, "it depends on the resident's behavior- it varies day to day". The staff stated there are (3) caregivers and (1) Med-Tech and that is "considered fully staffed" and staff will document both "End of shift logs" and shower logs for each resident. The RCC stated on 7/31/23 "residents are getting showers- it is more of lacking of charting". The RCC explained that housekeeping staff has been trained on changing resident clothes to assist caregivers, and there are (3-4) caregivers and (1) Med-Tech scheduled during the daytime hours, and they will also schedule staff through an outside staffing agency. The RCC stated she has never instructed staff to "just sign the book" that the shower was given when it was not. LPA was recently provided with documentation of the weekly narcotic audits being conducted, since 8/28/23, by the Administrator and the RCC. Additionally, the Administrator provided documentation of (2) other medication audits with an outside provider and pharmacy. cont on 9099C-2... 9099C-2...On 7/31/23, LPA Calzada reviewed the July shower log/binder showing documentation for each resident. LPA observed that some days were signed by staff as having given a shower to the resident, and other days were marked "refused". On 10/17/23, LPA reviewed the October shower logs with the RCC for all residents and observed only a few scheduled showers to not have staff initials on the scheduled day. The RCC and Administrator were certain residents received showers on many of these days and would discuss documenting better with staff. A Med-Tech staff stated that she was asked to just sign the ADL binder, when the month had ended, if there were scheduled showers that were not initialed as being given by staff on the log. A caregiver stated that she is trained to initial the shower log binder at the completion of each shift to note which scheduled showers were given. This caregiver indicated she has never been told by lead or manager to just initial the shower was given when it was not. The staff explained that some residents definitely refuse showers and staff will do a "change of face" and notify the Med-Tech. This staff stated staff communication is much better now in recent months and resident concerns and issues are discussed more at the cross over meetings at shift change. There were no resident names or dates giving when the ADL's were allegedly missed. Based on information obtained during the investigation, LPA finds this allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 59-AS-20230725143417

Allegation investigated: Facility does not have sufficient staff to meet the needs of the residents in care.

On 10/12/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegation and met with Resident Care Cordinator (RCC), Ashley Astahl. LPA conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. The complaint identified R1 as a resident who did not receive adequate incontinence care and oral hygiene. Records review and interviews found that R1 was discharged in May 2023. The allegation did not state specicific dates or caregivers alleged to not provide care. Interviews found that R1 would need 1-2 staff for incontinence care. While R1 required a high level of physical assist, R1 could usually idenify when they needed incontinence care. Because R1 had frequent incontinence assistance, staff had a schedule of care and checked in with R1 often between schedule care. Unsubstantiated An absence of oral hygiene was not witnessed by those staff interviewed. As R1 is unable to recall historical events, has moved from the facility, and specific details of a specific event are not provided the department does not find sufficient evidence to substantiate this allegation. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with RCC.the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 59-AS-20230720164140

Allegation investigated: Staff are mismanaging resident's medications. Staff are not keeping accurate medication records.

On 10/12/23, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Ashley Stahl, RCC, to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. Staff are mismanaging resident's medications- The allegations did not provide specific timelines for when events were alleged to have occured. The alegation of medication mismanagement has been investigated as well by LPA Calzada in concurrent complaints and was substantiated for 87465(a)(4) failures to provide medications as prescribed. Citations were issued on7/20/23, 7/31/23, 8/9/23 and 9/29/23 for related issues that are currently in plans of correction. Therefore an addiional citation is not issued at this time. Regarding Staff are not keeping accurate medication records- Interviews and records reviews found regular lack of consistent and complete recording of PRN use for residents as required. Substantiated There was a regular lack of consistent and complete recording of PRN use for residents as required. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with RCC . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 59-AS-20230823082439

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(3) · Plan of correction due date: Nov 9, 2023

Incidental Medical and Dental Care.(c )(3)A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement was not met as evidenced by records and interviews That found PRN use by residents are not consistently recorded as required. This posed a potential risk to residents.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: Licensee will submit the procedures for administering and documenting resident PRN use and staff training of the procedures to CCL by the POC date of 11/9/23.

Allegation investigated: Staff do not provide adequate supervision resulting in resident hitting another resident in care.

On 10/12/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with RCC Ashley Stahl. LPA conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. It was alleged that an altercation occurred between two residents. A date or time was not identified, niether were the residents alleged to be involved. Only that it occured near R1's room and the other resident allegedly stated R1 had hit them. Records reviews and interviews found R1 to have dementia with behavioral disturbance. Staff notes for a period around when the time thecomplaint was made, found no record of such an incident. Interviews found that R1 may raise their voice and swat at staff, staff generally have not witnessed events of R1 hitting other residents. All staff interviewed stated that it could be possible for R1 to strike at another resident who is in R1's space but they have not witnessed such events. R1 generally stays to themselves except for staff Unsubstantiated interactions and care. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with RCC.the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 59-AS-20230828113616

Allegation investigated: Staff do not meet the training requirements.

On 10/12/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with RCC Ashley Stahl. LPA conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. It was alleged that staff do not receive training as required. A period of time was not identified, niether were the staff alleged to not be trained. LPA reviewed August 2023 staff schedules and a review of staff training- particularly staff who began to work at the facility in Aug 2023. S1 and S2 had the required 20 hours of training before working with residents. Their training is ongoing. Interviews of caregivers with whom S1 and S2 worked stated that all new employees undergo a period of training, without individual care assignments, until they demonstrate compitency. Unsubstantiated As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with RCC.the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 59-AS-20230830113344

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver an second amended page to a complaint investigation report (# 59-AS-20230504081443) delivered on 9/29/23. LPA discovered earlier today that the information was incorrectly copied/pasted in the prior amended 9099C-2 page. LPA met with Toni Jones, Administrator, and explained purpose of inspection. LPA provided a copy of the complete complaint findings for the above referenced complaint, which included the most recently amended page (9099C-2), any other amended pages and the original pages that were not amended. There are no citations issued in this report. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Oct 5, 2023

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to issue (2) additional citations related to substantiated complaint findings (# 59-AS-20230504081443) delivered on 9/29/23. There were (7) allegations substantiated but only (5) citations issued. LPA met with Toni Jones, Administrator, and explained purpose of inspection. The following (2) allegations were substantiated on 9/29/23 but were included in citations for (2) similar but separate allegations that were also substantiated. The Department has determined that it is appropriate to issue (2) additional citations for the following allegations: 1- Staff mismanaged resident’s medication and 2- Staff misinformed resident’s family about resident’s hospitalization. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (2) citations are being issued on the 809-D page attached. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 4, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87507(f) · Plan of correction due date: Oct 5, 2023

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Basd on documentation review, the Licensee did not ensure that item #25- Medication Safety, (listed in the Resident Handbook) which reads: "Medications will be Centrally Stored and monitored by Community Staff ", was followed, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: Licensee/Administrator has already requested to consolidate (R1's) current pharmacy into another pharmacy that will deliver directly to the facility. Administrator will attempt to consolidate all medication distribution into one pharmacy provider. Documentation to be provided by 10/18/23 of any consolidations .

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d)(5) · Plan of correction due date: Oct 18, 2023

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (5) Good character and a continuing reputation of personal integrity. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that the prior Administrator included accurate information only on the LIC624 submitted to the Department on/around 4/27/23 for the incident ocurring on 4/26/23 regarding (R1) going to the hospital, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: The Administrator who submitted the LIC624 is no longer employed at the facility. The current Administrator reviews all LIC624's prior to submission and will ensure their accuracy. There is no further POC action needed on this one.

Allegation investigated: Staff mismanaged resident’s medication. Staff did not ensure that resident received their medication Staff did not effectively communicate with resident’s family. Staff misinformed resident’s family about resident’s hospitalization. Staff did not give resident’s family copies of resident’s reports/documents upon request. Staff did not ensure that the restroom emergency pull tab was functional. Staff did not ensure that the resident restroom had paper products.

**This page was amended on 10/4/23 to note that all requested documentation was received as requested during the investigation. A new signature was also obtained.** Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete and deliver investigative findings to a a complaint received on 5/4/23. LPA met with Med-Tech, Gina Yanez (GY), who stated the Administrator, Toni Jones, was temporarily out of the building conducting a new resident assessment but would return shortly. LPA met with the Administrator at 1:45 pm. During the investigation, LPA interviewed the current Administrator, Resident Care Coordinator (RCC), (2) family members of resident (R1), and the Maintenance Director. LPA reviewed documentation pertaining to (R1), including but not limited to, physician's report, care plan, charting notes, and incident reports, Medication Administration Record (MAR), Admission Agreement. The results of the investigation are as follows: **cont on 9099C-1... Substantiated 9099C-1... **This page was amended on 10/4/23 to include additional information from the MAR that was provided to the Department during the investigation and to note that a separate citation will be issued on a 809 report, dated 10/4/23, for the following substantiated allegation.A new signature was also obtained ** Allegation: Staff mismanaged resident’s medication. Complaint alleges that (3) bottles of Galantamine (30 pills each) were filled and dropped off 3/17/23 at the facility. On 4/22/23, (R1's) family member was notified by staff that this medication was out and needed to be refilled. (R1's) family member confirmed with the pharmacy that the medication was last filled on 3/17/23 for a quantity of 90 pills and was told that the facility would determine where the missing pills were. (R1's) family members stated the Administrator during this time stated she was not aware of the situation and could not provide a resolution, and the facility “guessed” that the medication accidentally was assigned to another patient when (R1) was moved to that patients room and the medication was accidentally destroyed because the other patient was no longer at the facility. RCC stated on 5/12/23 that before the prior Administrator left the community, (S1) Med-Tech, called the family and said the facility was missing a bottle of medication for her Dementia. RCC confirmed the missing medication was Galantamine and (S1) claimed the bottle was missing, and the February bottle was at home for a while since it was a 90-day supply. RCC explained that (R1's) health care provider said the February bottle/medication was delivered to the family member's house. Both family members who were interviewed confirmed that (R1) never received the medication (3 bottles) with one member stating “she (R1) never got any of the 90-day medications, asserting they "disappeared"., and stated her father, had some supply of the same medication, same dosage, at his residence at another location. MAR for February 2023 and March 2023 appear to have staff initials in each box, as for other medications given on the same day and time (am); however, entries on 3/4 through 3/17 appear to also have a circle around them for the medication, Galantamine. There are no entries on the April 2023 MAR for Galantamine from 4/1- 4/7 or on 4/15 and 4/16, and for (2) other scheduled medications on these same days; there is an entry on 4/1 and 4/2 only for the medication, Tamsulosin, that it was administered in the morning. The MAR for May 2023 has entries on all days for Galantamine, except for on 5/13 and 5/14, which was also observed for medications, Losartan and Lovastatin. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. NOTE: A separate citation was not initially issued on 9/29/23 but is being issued on a separate report, dated 10/4/23. cont on 9099C2... 9099C-2.. **This page was amended on 10/4/23 to correctly state information regarding the MAR. This page was amended again on 10/5/23 due to the added information being inadvertently pasted in the middle of an unrelated sentence from the prior report** Allegation: Staff did not ensure that resident received their medication. On 4/22/23, (R1's) family member was notified by staff that this medication was out and needed to be refilled. (R1's) family member confirmed with the pharmacy that the medication was last filled on 3/17/23 for a quantity of 90 pills and was told that the facility would determine where the missing pills were. One family member stated that as of the day of the meeting, 5/2/23, she and family were never notified of the missing meds and (R1) did not receive this medication for several weeks. RCC stated on 5/12/23 "yes, there were (3) days of missed medications" and confirmed that the facility does use a MAR. LPA was provided with copies of MAR documentation from Jan 2023- May 2023, as requested. MAR for February 2023 and March 2023 appear to have staff initials in each box, as for other medications given on the same day and time (am); however, entries on 3/4 through 3/17 appear to also have a circle around them for the medication, Galantamine. There are no entries on the April 2023 MAR for Galantamine from 4/1- 4/7 or on 4/15 and 4/16, and for (2) other scheduled medications on these same days; there is an entry on 4/1 and 4/2 only for the medication, Tamsulosin, that it was administered in the morning. The MAR for May 2023 has entries on all days for Galantamine, except for on 5/13 and 5/14, which was also observed for medications, Losartan and Lovastatin. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff did not effectively communicate with resident’s family. Complaint states that on 4/26/23, (R1) was taken by a non-emergency ambulance provider to the ER and resident’s family was not aware until the following morning when resident’s granddaughter visited and noticed a hospital admittance band on (R1’s) wrist . One family member stated that no staff told her or her sister that (R1) had gone to the hospital. A second family member stated “staff said they tried calling all of us but they did not leave any messages when (R1) was sent to the hospital”. One member asserted that (R1) did not have a stomachache and was sent to the hospital they sent her to since it is a trauma center and (R1) hit her head. RCC stated on 5/12/23 that the facility documents when they contact residents' family members or POA in their charting notes. There were no charting notes available from 4/26/23 or 4/27/23. The Administrator at the time was not able to be interviewed. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. cont on 9099C-3... 9099C-3... **This page was amended on 10/4/23 to note that a separate citation was not initially issued for this substantiated allegation but is being issued on a separate report, dated 10/4/23** Allegation: Staff misinformed resident’s family about resident’s hospitalization. Allegation states that when (R1’s) family member visited (R1) on the morning of 4/27/23, she observed her to be wearing a hospital bracelet from 4/26/23, from another hospital than resident’s primary assigned one. When (R1’s) family inquired about the ER visit, they were told by facility staff (R1) had been sent to the ER for a UTI and then were later told that day by the Administrator that (R1) was sent out due to complaining of a stomach ache. The Administrator then indicated that (R1) was sent to the hospital in her primary medical group, when she was sent to another hospital in the area. One family member stated that no staff told her or her sister that (R1) had gone to the hospital. A second family member asserted “staff said they tried calling all of us but they did not leave any messages when (R1) was sent to the hospital”. One of the family members asserted that (R1) did not have a stomachache and was sent to the hospital they sent her to since it is a trauma center and (R1) hit her head. The other family member stated that at approximately 3:30pm on 4/27/23, the Administrator contacted (R1’s) other family member and asked her if she was going to pick up the “hard copy” prescription to get filled for the UTI. The Department received an incident report (LIC624), dated 4/27/23, which notes (R1) was sent to the ER on 4/26/23, at approximately 6:00 am by a non-emergency ambulance provider. The incident report notes that at approximately 6:00 am, (R1) had a “change in condition and was experiencing some discomfort” and was found on the floor by staff during room checks. It was decided to sent resident out for further medical evaluation. The LIC624 states that resident was taken to the assigned hospital through her health plan and that staff “contacted family”; however, when the family member called (R1’s) assigned hospital, there was no record that (R1) had visited the night before. Hospital discharge papers confirm that (R1) was sent to another hospital other than her assigned primary care hospital and was seen for a fall and UTI and was prescribed Cephalexin (Keflex 500 mg) for (7) days. Charting notes from 4/26/23 document (R1) was sent to a different hospital than the one indicated on the LIC624. The Administrator later indicated to the family members that (R1) was sent to a different hospital in the area and it was not mentioned that (R1) was sent out due to a fall. It was discovered that (R1) had a UTI after being sent out for the fall. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. NOTE: A separate citation was not initially issued for this substantiated allegation but is being issued on a separate report, dated 10/4/23. cont on 9099C-4.. 90099C-4... Allegation: Staff did not give resident’s family copies of resident’s reports/documents upon request. Allegation reads that (R1)’s family members had a meeting with the Administrator, on 5/2/23, and requested to get a copy of the incident report as well as the Internal Occurrence Report for when (R1) went to the hospital on4/26/23 and copies of all incident reports since resident moved in. The Administrator agreed to provide these copies later in the day but was not able to locate them, and she said she did not have time to look for them. The RCC stated that she attended the meeting also on 5/2/23 and (R1's) family was provided with (1) incident report (LIC624) and (1) In-House incident report during the meeting. RCC stated she heard the Administrator agree to provide copies of all other LIC624's for (R1) and isn't sure if they were provided, but the Administrator was somewhat reluctant to do so. RCC stated that the incident from 4/26/23 is a separate one from the incident in (R1's) records that is documented in the charting notes and on an internal incident report from 4/28/23. (R1) was not sent to the ER on 4/28/23 after speaking with her family member. It should be noted that (R1) had began antibiotic treatment for a UTI following the visit to the hospital on 4/26/23 and could possibly have had a fall again on 4/28/23. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff did not ensure that the restroom emergency pull tab was functional. Complaint alleges that the pull cord in (R1's) restroom was not working from on/around February- May 2023 and was told that it had been fixed earlier than it actually was. Tour conducted on 5/12/23 -LPA tested the pull cord in (R1's) bathroom and observed it to light up as well as the pull-cord near (R1’s) bed. LPA tested the pull cord in a staff bathroom at 11:35 am and observed the red light to appear and tested a pull cord in a second staff bathroom and observed the light to appear at 11:45 am. LPA tested the pull cord in a second resident’s room and observed it to light up when activated. On 5/12/23, RCC showed LPA during the tour that this pull cord's location appeared on the monitor in RCC's office as having been pulled at the noted day/time and was "red" on the screen. The alert for (R1's) room appeared "purple" on the monitor in RCC's office. cont on 9099-C-5.. 9099C-5.. One family member stated on 7/26/23 the pull-cords were "non-functional" in (R1’s) bathroom from Feb 2023- May 2023 and she told the Administrator at the time, but they were not fixed timely. The same family member indicated she has "never seen a necklace or bracelet on (R1)".The Maintenance Director stated he wasn’t working at the facility from February-April 2023 and when he returned to the community on/around July 2023, he replaced all of the batteries to ensure all pull cords were working, both in resident rooms and staff areas. On 5/12/23, RCC stated a report for the response time was printed last week and that last week, not all pull cords were working but now they are working 100%. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff did not ensure that the resident restroom had paper products. Paper towels or wipes were not available in the resident restroom. LPA conducted a tour on 5/12/23 in (R1's) private bathroom. LA did not observe any paper towels or a paper towel dispenser in (R1's) shared bathroom. LPA observed (2) small cloth towels on a single towel rack. RCC stated on 5/12/23 that the facility fills each residents paper products in their individual bathrooms everyday and each resident receives 2 extra paper products On 9/26/23-LPA did not observe any towels, cloth or paper, to be in the bathroom. Administrator stated laundry was being done since (R1’s) laundry hamper was not in her room. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (6) citations are issued on the 9099-D pages. Exit interview. Copy of report and appeal rights provided. 9099A-C-1... Allegation: Staff were not available and visible at the facility. Complaint alleges the Administrator at the time was informed on several occasion, at different times of the day, staff was not available, and at other times a staff member was not visible and able to be located. On 5/12/23, RCC stated that during the AM shift there are 3 caregivers and 1 med tech on duty. RCC indicated that there are 10 staff on duty including house keepers during the AM shift. RCC stated that during the PM shift there are typically 3-4 caregivers and 1 med tech on duty. RCC stated that during the NOC shift there are 2 caregivers that are med tech trained. LPA has observed multiple staff on several visits made to the community from May- September 2023.n Additionally, the Ombudsman has made multiple visits to the facility and has not observed staffing to be insufficient. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff did not ensure that resident was properly dressed. Complaint states that during one visit, (R1) was wearing men’s pants that had an odor of urine; on another visit, (R1) was not wearing any undergarments, and on a third visit, (R1) was in the same clothes she was wearing the day before. LPA observed (R1) on 5/12/23 to be wearing a blue turtleneck sweater, pink bow in her hair, and to be sitting in her wheelchair. RCC showed LPA (R1’s) dresser and closet- LPA observed sufficient clothing and incontinent products on hand. On 7/31/23, LPA and one staff observed (R1) present in her room and to be dressed in clean, dry clothes with no incontinent odors noticed. LPA and the Administrator observed (R1) on 9/26/23 to be dressed in clean, dry clothing and wearing several bracelets. There were no incontinent odors observed Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. cont on 9099A-C-2... 9099A-C-2... Allegation: Staff did not ensure that resident had adequate bedding.During one of visits, (R1) only had one sheet and her personal lap blanket. Her feet had no socks and were ice cold. LPA conducted a tour on 5/12/23 and observed (R1's) bed to be made with (2) sheets and a blanket. An additional (3) crocheted blankets were folded on top of the bedspread. On 7/31/23, LPA observed a plastic protector on the mattress. (S2) showed LPA the different layers on the plastic protector- 1- cloth, 2- sheet, 4- cotton chuck, 5- disposable chuck. (S2) stated incontinent like 89% of the residents. AB stated all incontinent residents have both a cotton and disposable chuck on the sheets. (7) other resident rooms were inspected and all rooms were observed to have clean, dry linens on the beds with no significant incontinent odors present. On 9/26/23, LPA and Administrator observed (R1’s) bed to be made and all layers, sheets, incontinent pads and blankets to be clean and dry. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- Allegation: Staff did not ensure safe keeping of resident’s personal property.Missing items from (R1’s) room which include, slippers, jackets, plant and walker. During one of visits, (R1) was not in her wheelchair and was using a wheelchair with someone else’s name on it. When addressed, staff took her back to her room to switch wheelchairs and returned with a completely different wheelchair other than her own. On 5/12/23, RCC stated (R1's) daughter put a lock on her door. RCC stated she/Admin tell families that "it's Memory Care" and residents wander and things can disappear. RCC confirmed that R1 did have clothes missing and explained that there is a resident that likes to "shop" and goes in (R1's) room. On 7/26/23, R1’s family member stated that things disappear and some residents go in other residents' rooms, mentioning resident, ((R2), who takes items and exchanges them for cigarettes. On 9/26/23, another family member stated that RR has had bracelets stolen from resident, (R2) and "(R2) is a problem" as she has seen (R1's) things in (R2's) room. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Sep 29, 2023 · control 59-AS-20230504081443

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 2, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on interviews conducted, the Licensee did not ensure that the medication Galantamine, for (R1), was administered as ordered on/around April 2023 and that no medication went missing, which posed an immediate health and safety risk to residents in care. (R1) missed several days of this medication.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee/Administrator agree to continue with staff training, pharmacy audits, and reviewing the documentation every week. Documentation to be provided by 10/2/23 of what has been completed so far.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Oct 13, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement is not met as evidenced by: Based on interviews conducted, the Licensee did not ensure that family members were notified that (R1) was sent to the hospital, and for what reasons, on 4/26/23, which posed a personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee/Administrator conducted staff training in the last month regarding emergency assistance protocols. Documentation to be sent by 10/13/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 13, 2023

87303 Maintenance and Operation a) 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 interviews conducted, the LIcensee did not ensure that all pull cord devices were in working order, including in (R1's) bathroom, from approximately Feb- May 2023, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee/Administrator agree to continue check weekly with the Maintenance Director. All bathrooms and pull cords are being checked weekly. Documentation to be submitted by 10/13/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3) · Plan of correction due date: Oct 13, 2023

Reg 87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (D) Hygiene items of general use such as soap and toilet paper. This requirement is not met as evidenced by: Based on observation on 5/12/23 and 9/26/23, the Licensee did not ensure that there were paper towels or cloth towels available for use in (R1's) bathroom, which posed a potential heatlh and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee/Administrator agree to discuss options regarding installing a paper towel roll holder or dispenser. Provide documentation of solution by 10/13/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 13, 2023

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evicenced by: Based on interviews conducted, the LIcensee did not ensure that (R1's) family was provided with all LIC624's since moving to the community after they were requested.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee.Administrator agree to discus with RCC on this process and provide documentation of the protocols to be followed. Documentation due by 10/13/23.

Allegation investigated: Staff do not maintain facility clean and sanitary at all times Staff do not assist resident with grooming

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open and close a complaint received anonymously on-line on 09/26/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During today's inspection, LPA discussed the allegations with the Administrator and (2) staff. LPA also inspected the shared room that is referenced in the complaint with the Administrator and attempted to speak to both residents who occupy it. The results of the investigation are as follows: cont on 9099C-1.. Unfounded 9099C-1... Allegation: Staff do not maintain facility clean and sanitary at all times. Complaint alleges that resident's family member visited the resident and observed the resident's mattress to be soiled with urine and to contain urine stains. The complaint does not indicate which resident in the shared room this allegation pertains to. LPA and Administrator inspected the shared room referenced in the complaint, including the bathroom. LPA observed each resident's bed to be made and the bedding, and protective coverings (Chux) to be clean and dry. Additionally, LPA did not observe any incontinent odors in the room or near the beds. One staff who works on the "am" shift, stated that when (R1's) family visits, (R1's) bed is made and no complaints have been made regarding the allegation. This staff stated that (R1) will tell staff when she needs to use the bathroom. The same staff stated that both residents are "heavy whetters" and (R2) had (2) outside care providers visit today and there were no complaints made to staff about (R2's) bedding needing to be changed. A second staff, who works on the "pm" shift stated he has never seen either resident's bed soiled and needing to be laundered and confirmed caregivers will assist housekeeping with changing resident's linens. Due to their Dementia diagnosis, both residents were unable to communicate to LPA if staff changes their linens timely. The Ombudsman also recently investigated this allegation and did not find any evidence. Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff do not assist resident with grooming. Complaint alleges that resident's teeth were observed to be layered with food, and the resident's blouse had food on it. The complaint does not indicate which resident in the shared room this allegation pertains to. LPA observed resident (R1) to be wearing clean clothes. Administrator and LPA were unable to get (R1) to smile fully to show if her teeth were clean, but no food pieces were seen when (R1) was talking. (R1) was upset at the time of the inspection. cont on 9099C-2... 9099C-2.. LPA attempted to speak to resident (R2) who was sitting in a wheelchair in the dining room. (R2) was not able to engage in conversation with LPA and did not show her teeth when LPA was observing her. LPA did observe what appeared to be a small area on the lower area of her T-shirt to be stained with food possibly; however her jacket was observed to be clean and free from any food spots. Two staff stated that (R1) is a relatively neat eater and staff will usually use a bib to help keep her clothes clean. One staff stated that (R1) will let staff know if something is bothering her and will generally allow staff to brush her teeth. A second staff stated (R1) does not usually get food stuck in her teeth. Both staff interviewed stated that (R2) eats pureed food only and uses a bib since she is a messy eater. One staff indicated that (R2) is able to eat independently. Both staff confirmed that (R2) does not get food stuck in her teeth but occasionally gets food spilled on her clothes, especially her shoes. One staff indicated that it can be challenging to brush (R2's) teeth, so staff will use a tooth sponge. Due to their Dementia diagnosis, both residents were unable to communicate to LPA if staff changes their clothes, when soiled, and brushes their teeth when needed. The Ombudsman also recently investigated this allegation and did not find any evidence. Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 26, 2023 · control 59-AS-20230921164843

Allegation investigated: Staff do not properly maintain a resident's room while in care Staff do not ensure a resident has clean bedding Staff did not keep the facility free from pest

Licensing Program Analyst (LPA) Sabrina Calzada and Associate Government Program Analyst (AGPA) Brian Lam arrived unannounced to open and close a complaint received anonymously on 09/05/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. LPA discussed the allegations with the Administrator, Activities Director, Maintenance Director, (2) culinary staff, (1) housekeeper and (1) caregiver and toured the interior of the facility, including the common areas, (4) random resident bedrooms and (2) dining rooms, and the staff breakroom. The results of the investigation are as follows: Allegation: Staff do not properly maintain a resident's room while in care. The anonymous complaint did not provide a specific resident name or room number and only says a female resident's room and the carpet smell of urine. LPA conducted a tour of the common areas and resident rooms and did not observe any strong incontinent odors and the carpets were observed to be cleaned recently and are scheduled to be cleaned by an outside company within the next week. **cont on9099C-1.. Unfounded 9099C-1.. Interviews with the Maintenance Supervisor, housekeeping, caregiver all confirmed individual resident rooms are cleaned regularly, including the bathrooms and carpets/flooring, per the schedule, and every two months, an outside company cleans the flooring in the common areas and in resident rooms as well as all furniture. In addition, caregivers will assist housekeeping by vacuuming or sweeping the flooring in resident rooms. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff do not ensure a resident has clean bedding. The anonymous complaint did not include a specific resident name or room number and only says a female resident's room. LPA conducted a tour of the common areas and resident rooms, observing beds that were not made, and did not observe any strong incontinent odors or bedding to be soiled. LPA recently toured rooms and checked resident bedding in August on at least (2) occasions and did not observe any soiled linens. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff did not keep the facility free from pests. Allegation reads that the complainant saw a roach in her mother's room. There is no specific name or room number provided or day/time. A tour was conducted during today's inspection in the kitchen area, laundry area, staff break room and (2) resident dining rooms. LPA also observed underneath the kitchen sinks. In all areas toured, there were no roaches or other bugs observed. Both culinary staff indicated they have not seen any roaches recently in the kitchen. The Activities Director stated she she saw a "gold colored" bug that was "maybe a roach" trying to enter the resident dining room from the outside, this morning. This was an isolated incident. LPA was provided with a recent invoice for service provided on 7/29/23, from an outside pest control company. The Administrator confirmed that the facility receives regular scheduled pest control treatments. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 7, 2023 · control 59-AS-20230905164202

Allegation investigated: Facility is not taking necessary precautions to prevent the spread of scabies

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint investigation received anonymously on 8/18/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. LPA also briefly met wiith Ashley Stahl, Resident Care Coordinator (RCC). LPA discussed the allegation with the Administrator, RCC and (2) caregivers. LPA observed resident rooms of residents who had a diagnosis of scabies and reviewed documentation. The results of the investigation are as follows: LPA was informed of a scabies outbreak with (2) residents on 8/9/23, when resident (R1) was sent to the ER due to showing signs of itching and having a rash on her body. R1 returned the same day but without a diagnosis of scabies. R2 was also sent to the ER on 8/9/23 due to itching and having a rash that covered her whole body. R2 returned the same day with a diagnosis of scabies and prescription creme for treatment. LPA received a completed incident report (LIC624) for R1 and R2 on 8/11/23. Also on 8/11/23, LPA received a completed LIC624 for resident (R3) who went to the ER on 8/10/23 for the same signs of itching and a rash. R3 returned the same day with a diagnosis of scabies and prescription creme. cont on 9099C-1... Unfounded 9099C-1... LPA received a completed LIC624 for resident (R4) on 8/15/23 noting resident was sent to the ER on 8/12/23 for signs of itching and a rash. R4 returned the same day with a prescription creme for scabies. R4's roommate was moved from the shared room upon R4 showing signs/symptoms of scabies. LPA and Administrator observed R1 and R2's lower arms on 8/22/23. R1 stated she still has some itching and needs another treatment; however, a staff stated that a nurse saw R1 yesterday and the rash has cleared and R1's arms commonly appear dry and red. R2 was observed to have a slight rash on her lower arms and was not able to state if her arms are itchy when asked. LPA and Administrator observed R3's room and observed an upholstered chair in the room. Administrator agreed to have the chair cleaned following the scabies outbreak. LPA observed R4's room to be clean and not contain any upholstered furniture. LPA asked (2) staff if they were aware of any staff contracting scabies recently, and both said they were not. One staff confirmed that all (4) residents received both doses of the prescription treatment creme, affected residents had their clothing washed immediately following the diagnosis, on the NOC shift, and carpets/flooring was cleaned also. The same staff stated that R1 and R2 were seen by a nurse yesterday and R2 will be receiving a third dose of medication, which is expected to arrive by tomorrow, since R2 still has some rash visible. Staff asserted that all staff have been careful, "very cautious" and wearing PPE as required. RCC confirmed there were (4) residents who contracted scabies in August 2023 and there have been no staff with this diagnosis. RCC confirmed all residents received two treatments of the prescription creme for scabies, she contacted local public health following each case and followed the facility's Infection Control Plan immediately following the first cases. LPA observed a quarantine sign to still be posted outside residents, R1 and R2's room. RCC indicated that all infected residents were quarantined in their room for the designated period and if the residents went in the common areas they were redirected back to their rooms. LPA reviewed the Medication Administration Record (MAR) where it's noted R1 and R2 were administered the initial dose of Permethrin creme on 8/11/23; R4 on 8/12/23 and R3 on 8/15/23. Administrator to remind staff to enter their initials every time a dosage is administered. Based on information obtained during the investigation, LPA finds this allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Aug 22, 2023 · control 59-AS-20230818104727

Allegation investigated: Staff are not meeting resident's hygiene needs resulting in resident not staying dry.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint investigation received anonymously on 8/18/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. LPA discussed the allegation with the Administrator, RCC and (2) caregivers. LPA reviewed documentation from resident (R1) who is the subject of the complaint. The results of the investigation are as follows: Complaint alleges that resident is having urine infections due to not staying dry. Administrator confirmed that there is no record of resident having a recent urinary tract infection (UTI). Both the RCC and a Med-Tech staff stated that R1 had a UTI several months ago, and the only recent medical intervention has been bladder surgery and follow up care for removing a catheter. cont on 9099C-1... Unfounded 9099C-1...LPA and Administrator observed R1 to be resting in her room in her wheelchair. LPA observed resident's bed to be made and the linens and chucks to be dry underneath. LPA observed a supply of incontinent products also in the room and attached bathroom. Administrator assisted resident in transferring to her bed to take a nap. LPA did not note any incontinent odors to be present in the room. Interview with a caregiver staff revealed that she sometimes assists resident with incontinent care, resident cooperates well with staff, and staff will check on resident at least every 2 hours. This caregiver stated that resident has not had any urinary tract infections. A Med-Tech staff indicated that resident had surgery for bladder cancer and is currently on hospice. Staff stated that resident has not had a UTI but ripped out a catheter around May 2023 and had some blood spotting following surgery in May, one time, and so hospice was called. Staff stated that resident is very conscious of when she needs to use the bathroom and will ask staff for assistance, even though she is incontinent. LPA reviewed resident's facility file and hospice binder and noted resident began hospice on 5/11/23. Based on information obtained, LPA finds the allegation to be finding that the complaint is UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. The following Technical Advisory Note is issued related to a review of resident's file. The complaint also alleges that resident ran out of two medications. Interview with a lead Med-Tech revealed that resident's hospice provider will visit once or twice weekly and takes care of all medication orders, every 7 days. Medication refills are also delivered to the facility. LPA reviewed MAR for August and observed all ordered medications were received and administered timely. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Aug 22, 2023 · control 59-AS-20230817142551

Allegation investigated: Staff did not prevent resident from wandering from facility Facility has no Administrator

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint investigation received anonymously on 8/15/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. LPA discussed the allegations with the Administrator, RCC and (1) Med-Tech. The results of the investigation are as follows: Complaint alleges that a new male resident keeps leaving the building. There is no resident name provided in the anonymous complaint. All staff interviews revealed that the last time a resident eloped from the facility was on 6/29/23 (7:30 pm), the same day that same resident moved to the community. There have been no additional elopements. Based on information obtained, LPA finds the allegation to be UNFOUNDED. cont on 9099C1. Unfounded 9099C-1.. Facility has no Administrator. Complaint alleges there is no Administrator overseeing the building. The facility currently has an appointed Administrator, effective 8/18/23. LPA was informed of the change by email on 8/18/23 and provided with the necessary documentation. During June and July 2023, the facility had an Interim Administrator. In August and May 2023, the Regional Director and Resident Care Coordinator were covering as Administrator Designee. The Regional Director has an active RCFE Administrator certificate. Prior to May 2023, there was a full-time Administrator in place. Based on information obtained, LPA finds the allegation to be finding that the complaint is UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of repot provided to the Administrator.the state’s words, verbatim · CDSS document, Aug 22, 2023 · control 59-AS-20230815101443

Allegation investigated: Staff are mismanaging resident's medications.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint investigation for the above allegation. LPA met with Ashika Bennanon, Med-Tech, who stepped out of the staff meeting taking place and directed LPA to an empty office area. LPA later met with Ashley Stahl, Resident Care Coordinator (RCC) and explained purpose of inspection. LPA observed a resident (R2) being taken by a non-emergency ambulance provider to the hospital for medical attention. Also occuring during today's inspection was the fire department arriving due to the smell of smoke coming from inside resident walls in two rooms. The source of the smoke was determined to be related to a repair made by an HVAC company yesterday. Residents were moved to the other side of the building and no one was injured. During today's inspection, LPA discussed then allegation with RCC and (3) Med-Tech staff. LPA also reviewed medication documentation pertaining to resident (R1). The results of the investigation are as follows: Substantiated 9099C-1...LPA reviewed a letter that was faxed to the community on 7/28/23 requesting changes be made following resident's medical evaluation that day: Discontinue Medication, Prozac (Fluoxetine) 10 mg Discontinue Risperidone (scheduled and PRN doses) Start Olanzapine 2.5 mg po qhs for 3 days , then increase to 2.5 mg, po bid on 7/31/23d Continue Lorazepam, as PRN, and Melatonin and Donepezil at current doses LPA reviewed a Medication list faxed to the facility on 8/8/23 (9:23 am) noted as "New and Updated list as of 4 pm- 8/7/23". Med-Tech staff indicated that medication changes hadn't been inputted into the system to be reflected on the MAR as of 8/7/23. Resident's Nurse Practitioner came out to the facility on 8/7/23 to review the medications as she was upset the updates to resident's medications had not been implemented on the MAR on/around 7/28/23. Specifically, changes to resident's medications were not entered into the system on/around 7/28/23. MAR records for August 2023 reflect (4) medications discontinued on 8/8/2023 and (3) medications added effective 8/8/2023, and show a total of (10) medications listed on the MAR, which agrees with the medication orders. Discontinued medications as follows: Fluoxetine 10 mg tab; Acetaminophen/Hydrocodone 325-5 mg tablet; Ibuprofen 600 mg tablet; and Lorazepam 0.5 mg tablet. Medications added: Multivitamin with minerals; PRN Mineral Oil; and Tea Tree Oil on toenails daily. Med-Tech staff indicated that resident's nurse practitioner was provided with a signed/updated MAR for August on 8/7/23, as requested. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 9, 2023 · control 59-AS-20230807090749

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 10, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on documentation reviewed and interviews conducted, the Licensee did not ensure that medications changes for resident (R1)faxed to the facility on 7/28/23 were updated timely in the system to be reflected on the MAR, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 9, 2023

Plan of correction: Licensee/Administrator agree to submit a training plan to the Department by 8/10/23 regarding medication training, to include timely entering of medication orders in the system and correct documentation/initialing on the MAR. Documentation of completed staff training to be submited to the Department by 8/23/23 to include agenda and attendees.

Allegation investigated: Staff yelled at resident Staff failed to treat resident with dignity and respect

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint investigation received anonymously on 89/3/23. LPA met with Ashika Bennanon, Med-Tech, who stepped out of the staff meeting taking place and directed LPA to an empty office area. LPA later met with Ashley Stahl, Resident Care Coordinator (RCC) and explained purpose of inspection. LPA observed a resident (R2) being taken by a non-emergency ambulance provider to the hospital for medical attention. During today's inspection, LPA interviewed the RCC and (1) staff. LPA also reviewed notes from the Ombudsman's visit to the facility on 8/4/23 regarding the alleged incident. The results of the investigation are as follows: Allegation: Staff yelled at resident. Complaint alleges that a random driver was stopped on the side of the ride to use the navigation system in his/her car and heard a female staff yell at a resident by the gate. Allegation also states the staff was blonde-haired. **cont on 9099C-1... Unfounded 9099C-1... Ombudsman notes she used the distance measurement app on her cell phone to check the distance between the outside curb area from Old Auburn Road to the resident gate areas. Based on the distances determined, it's unlikely that anyone who was on Old Auburn Road could hear yelling or noise from inside any of the resident gate areas, considering the traffic levels on Old Auburn Road. Additionally, RCC stated she and the Ombudsman went outside and were unable to hear any noise. Staff stated also in an interview that given the triple digits for heat temperatures over the weekend of July 29/30, 2023, it's unlikely anyone would have their window down also, and when she has parked on the street she is unable to hear any conversations from the community due to the noise of the traffic on Old Auburn Road. RCC and staff interviewed indicated there are no blond caregivers currently working during any shifts, including the weekends. RCC confirmed she was not at the facility on the said weekend. LPA has conducted several recent inspections at the community and has never observed staff to yell at any residents. Based on information obtained during the investigation, LPA finds this allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff failed to treat resident with dignity and respect. Complaint alleges the same staff was upset and yelled at a resident, "if I have to come out here on my day off again you will get yours.". Ombudsman's notes from the 8/4/23 inspection indicate that she met and spoke with several residents who indicated they are happy and comfortable with the care at the facility. Additionally, several residents who were near the front entrance area that day, appeared "healthy, dressed and groomed appropriately". Another resident who had previously fallen and sustained a bruise indicated she was doing well, was able to walk without any assistive device and "her facial injuries were healing". LPA has conducted several recent inspections at the community and has always observed staff to treat residents with dignity and respect. Based on information obtained during the investigation, LPA finds this allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided to RCC.the state’s words, verbatim · CDSS document, Aug 9, 2023 · control 59-AS-20230803082156

Allegation investigated: Staff did not provide resident with medication as prescribed

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint investigation for the above allegation. LPA met with Ashley Stahl, Resident Care Coordinator (RCC) and explained purpose of inspection. Also present in RCC's office was Ashika Bennanon, Med-Tech. During today's LPA discussed allegation with RCC and Med-Tech staff. LPA stated the complaint received on 7/28/23 was filed anonymously and only references a male resident with no specific information as to the resident's name or room number. The complaint alleges a resident was administered narcotics,specifically Norco, incorrectly. RCC provided names of the male residents and stated that resident (R1) recently had a missing bottle of Norco (Hydrocodone) 325-5 mg, and R1 refuses medications and hospice is aware. Med-Tech stated that several of these residents take Lorazepam and one resident takes Morphine. cont on 9099C1... Substantiated 9099C-1... The Department received an incident report (LIC624) by email on 7/21/23 from the Interim Administrator reporting that a bottle of Norco was missing for resident (R1) from the medication room. The Log Book finder notes the bottle of Norco was logged on 7/14/23 (8:53 pm), by staff (S1), as received; however, there is no record of the medication on the Centrally Stored Medication and Destruction Record (LIC622). LPA reviewed the Medication Administration Record (MAR) for R1 for July 2023 and observed the medication to have been last initialed as administered, twice daily, as ordered, on 7/17/23. LIC624 reports that R1 missed one day of Norco medication on 7/20/23; however, there were no staff initials entered for days 7/18/23, 7/19/23, 7/20/23, noting the medication was either administered to or refused by the resident. Med-Tech staff stated a PRN prescription for Norco replaced the scheduled prescription effective 7/21/23. LPA observed notes on the MAR that scheduled Norco was discontinued on 7/22/23. Based on information obtained and reviewed, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 31, 2023 · control 59-AS-20230728133706

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 14, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on documentation reviewed (LIC624 and medication documentation), the LIcensee did not ensure that resident (R1) was administered Hydrocodone (Norco) 325-5 mg table from 7/18/23-7/20/23), due to a bottle of the medication missing, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 31, 2023

Plan of correction: Licensee/Administrator agree to conduct additional staff training on the 3-step process in logging narcotics for staff accountability. Documentation of staff training (agenda/attendees) due to the Department by 8/14/23.

Allegation investigated: Staff are mishandling resident's medication.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the complaint investigation and deliver findings for the above allegation. LPA met with Editha McCullough, Interim Administrator, and explained purpose of inspection. During the investigation, LPA interviewed (2) Med-Tech staff and the Administrator. LPA interviewed (1) resident and attempted to interview (2) residents but was unable to obtain any pertinent information. LPA also reviewed medications being administered to (3) residents, including the associated orders and documentation, and toured the interior of the community. The results of the investigation are as follows: Both Med-Techs stated they occasionally do find a pill or medication on the floor as there are a couple of residents who pretend to take their medication and "pocket it", but most residents “know their routine” and are generally good at taking their medication. One Med-Tech indicated that she and other staff do document when a resident refuses medications and also inform the physician. cont on 9099C(1).. Substantiated 9099C-1... One staff stated medications are sometimes not ordered timely, explaining each Med-Tech is in charge of ordering medications. Staff explained that the facility previously tried a system of ordering 7 days out, but it didn't work, and sometimes a resident will not start an antibiotic medication until the next day and they receive their first dose at the hospital. (1) resident who was interviewed stated he has not had any issues with receiving medications and they are the same every day. Medication being left out. LPA toured the facility on 6/28/23, 7/6/23, 7/13/23 and 7/20/23 and did not observe any unsecured medications to be on the floor or in the resident hallways. Staff interviewed stated medications are delivered using the med cart and usually "we administer them in the dining room- there are more eyes on the meds with dining staff there". LPA observed both dining rooms on 7/20/23 and did not observe any medications on the floor during/after S1 administered noon medications to a few residents. LPA and S1 conducted a medication audit for (3) residents on 6/28/23 in the facility medication room. Medication orders were compared to medications being administered and documentation on the Centrally Stored Medication List (LIC622) and Medication Administration Record (MAR) was reviewed. The following discrepancies were noted for (2) residents, as follows: For resident (R1)- There were no errors in (11) of (15) medications. Medication counts on hand did not match with the start date entered on the LIC622 for Cranberry supplement, Multi-Vitamin Centrum, Divalprox and Olanzapine, showing a discrepancy of (2) to (12) days. There was no start date listed on the LIC622 for Senna 17.2 mg and PRN Olanzapine, 5mg- expired 4/12/23. New medication of Olanzapine was ordered on 7/8/23 and will be received by 7/28/23. S1 stated resident has not taken this recently as it has not been needed. There were (2) lose pills observed in resident's red centrally stored box that appeared to have fallen out of the bubble pack. Medication was discarded per protocols. For resident (R2)- there were no medication errors noted on (3) of (3) medications and there were no lose pills in the red centrally stored box. For resident (R3)- There were no errors in (5) of (7) medications reviewed. The medication Fluoxetine 20 mg was missing (1) tablet based on the start date and medication count. The medication Risperidone 0.5 mg, ordered to be given as (1) tablet in the morning and (2) at bedtime, a start date of 6/10/23 was noted on the LIC622. There was no start date entered on the 30-day bubble pack. (13) tablets were administered on 6/28/23 (4:00 pm), or (4) days plus a morning dose, if administered as ordered. The medication count didn't match the start date entered on the LIC622. There were no lose pills in resident's red centrally stored box. cont on 9099C-2. 9099C-2... Based on information obtained and reviewed, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 20, 2023 · control 59-AS-20230626105103

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 31, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication count and record review on 6/28/23, the Licensee did not ensure that medications were administered as ordered for residents (R1 and R3), which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 20, 2023

Plan of correction: Licensee/Administrator agree to conduct staff training on medication management to include topics: Correct documentation by staff on the MAR and LIC622; how to log a new or refilled medication; importance of entering start date on the LIC622; process of calling timely for a refill Any other medication related topics Documentation to be provided to CCLD by 7/21/23 by email/fax of all Med-Tech staff. LPA observed documentation of completed training for "Medical Error Prevention" for (S2) on 7/17/23 and a new staff is in the process of completing.

Allegation investigated: Resident sustained pressure injuries while in care Facility staff are not meeting residents' hygiene needs. Facility staff are not providing residents assistance with toileting. Facility staff left residents in urine soaked bedding. Facility staff does not ensure that residents have clean bed linens.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on 4/12/23. The allegation: Resident sustained pressure injuries while in care was investigated by the Department and LPA investigated the remaining (4) allegations. LPA met with Editha McCullough, Interim Administrator, and explained purpose of inspection. T During the investigation, the Department conducted interviews and reviewed documentation, including medical records. The results of the investigation are as follows: Resident (R1) was admitted to the facility on 10/6/2021 from a skilled nursing after being hospitalized. Resident had been receiving home health services for an extended period of time before being hospitalized. A wound was noted on 10/5/21 on resident's right foot; a second wound was not noted until January 2022. In June 2022, resident had an annual assessment and Physical Therapy was recommended. Resident was admitted to the SNF in early June 2022 and was not discharged until late August 2022. cont on 9099C-1.. Unsubstantiated 9099C-1...On 9/2/22, the facility staff called home health staff and reported a wound on resident's buttocks. Charting notes from Sept 2022, note that resident had a rash on his body and was receiving care from home health nurses. Notes from October 2022 indicate that resident still complained of pain on his legs, feet and bottom and home health nurses were aware. Notes entered on 3/23/23 document resident was "100% bed bound" and refuses to get out of bed. Resident's Service Plan dated 8/22/22 notes that resident needs maximum assistance with bathing, dressing, grooming, dental, toileting, transfer/mobility, special care needs, cognitive, disposition and behaviors, sleep, communication, psycho-social engagement and medication management. Resident sustained only pressure injuries of stage 1 and 2 while living at the facility. Home health records obtained through 2/24/23, indicate,there were no stageable pressure injuries. Home health records did not reflect any concerns or neglect with facility care being provided, including with wound care. Residents family member stated during the investigation that resident does not currently have any pressure sores. Home health nurse was not interviewed due to no concerns noted in the home health records. Based on information obtained, the Department finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Facility staff are not meeting residents' hygiene needs. LPA reviewed the Shower Schedule binder for July 2023 and observed residents are scheduled for a shower at least twice weekly. The Administrator and a caregivers stated that staff is supposed to initial on the individual resident’s calendar page, at the end of the work shift, when a shower is given, but sometimes it is not done. LPA observed that almost all residents have multiple days that have not been initialed. If a resident is on hospice, the hospice staff will give the shower. cont on 9099C-2... 9099C-2... On/around April 2023, LPA was provided with names of (2) residents (R2 and R3) who are not receiving regular showers. Multiple staff interviews confirmed that R2 will regularly refuse a shower and it can take 2-3 staff to be able to get R2 in the shower. Additionally, R2’s family member is not able to get her to cooperate in taking a shower. R2 stated to LPA on 7/20/23 that she regularly takes a shower. LPA observed that R2 refused only (1) shower and has received (5) showers in July and R3 received (2) showers and refused (4) showers. R3 declined to talk to LPA. Staff stated they will try the next day or shift if a resident refuses a shower. Another resident, R4, who can be combative and refuse showers, received (4) showers this month and missed (2). The Administrator stated that once a resident refuses, staff cannot force a shower. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED-meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Facility staff are not providing residents assistance with toileting. LPA toured the facility multiple times in April 2023 and in July 2023 and did not observe any incontinent odors in the hallways or resident rooms. Interim Administrator stated she does rounds every morning around 7:30-8:00 and has implemented stand-up meetings, since July, where any issues are immediately brought to staff’s attention. Staff interviewed indicated there have no significant delays in providing incontinent care to residents. Administrator stated (3) care staff and (1) Med-Tech is usually sufficient during the morning and afternoon/early evening hours and (2) care staff, which includes a Med-Tech, work during the overnight shift. Staffing schedules reviewed show that there are at least 4 staff scheduled during the day time hours and 2 scheduled during the overnight hours. A staff who works during the overnight shift stated that residents are checked every (2) hours and provided incontinent care when needed, as well as during the day time hours, and incontinent care provided at night has improved in the last few months. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED-meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred cont on 9099C-3.. 9099C-3... Allegation: Facility staff left residents in urine-soaked bedding. LPA toured the facility multiple times in April 2023 and in July 2023 and did not observe any incontinent odors in the hallways or resident rooms. LPA and the Administrator observed specific resident rooms on 4/24/23 and noted each resident to have clean linen and the room to be odor free. One staff who works on the NOC shift stated that residents are checked every (2) hours and provided incontinent care when needed and it’s possible that soiled linens could be changed after the resident is changed, but the resident would not be left to lay in soiled linens for an extended period of time. A resident interviewed today said there have been no issues with caregiving or housekeeping staff not providing clean linens and towels and other staff interviewed said there have been no issues with residents being left in soiled bedding. Based on information obtained, the Department finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Facility staff does not ensure that residents have clean bed linens. LPA and Administrator toured on 4/24/23 and observed several resident rooms. LPA observed the bed to be made and the sheets and pad on top to be dry and odor free in all rooms checked. Interview with a housekeeper indicated that caregivers will change sheets and there have been no issues with caregivers not changing soiled sheets. Housekeeper stated she cleans the rooms and empties trash as often as daily. LPA observed linens to not be soiled or any incontinent odors on 7/20/23 when touring. A resident interviewed today said there have been no issues with caregiving or housekeeping staff not providing clean linens and towels. Staff who works at night, stated staff check residents every (2) hours during the overnight hours and provide incontinent care, when needed, including placing an absorbency pad on the linens. Residents were able to be interviewed indicated staff will change the linens timely. Based on information obtained, the Department finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided to the Interim Administrator.the state’s words, verbatim · CDSS document, Jul 20, 2023 · control 59-AS-20230412085616

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following the receipt of (2) incident reports (LIC624) on 7/19/23. LPA met with Editha McCullough, Interim Administrator, and explained purpose of inspection. LIC624's involve residents (R1 and R2) and an incident occurring on 7/18/23 at approximately 6:45 pm. LIC624's state that R1 hit R2 in the face but there were no marks, bruising or swelling on R2's face. Interviews with Med-Tech staff (S1) who was present during the incident confirmed the reported information that R1 did actually hit R2 and this is not typical behavior and was an isolated incident. S1 showed LPA the necklace that was pulled off of R2 and stated she would be assisting in getting it repaired promptly. S1 stated that R1 was sent out for a medical evaluation and returned the following morning with no new diagnoses or medication changes. S1 stated that both R1 and R2 have been walking around the community as they regularly do and will continue to have increased monitoring for the next two weeks. Administrator stated that R2's conservator was notified and declined to have resident sent out to the ER due to no visible signs of injury. R2 was still evaluated by an ambulance provided immediately following the incident. R1's responsible person was also notified. Administrator and S1 stated that residents can show "sundowning" behaviors in the evening and confirmed resident's (R1) care plan and assessment were updated. R1's service plan was reviewed and will be updated as needed. The facility took immediate action in seeking medical attention and notifying the responsible persons. There are no citations being issued on this report. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Jul 20, 2023

Allegation investigated: Residents in care sustained unexplained bruises

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint investigation for the above allegation. LPA met with Editha McCullough, Interim Administrator, and explained purpose of inspection. LPA also observed an Ombudsman staff to be present at the facility at the start of the inspection. During today's inspection, LPA interviewed Administrator, Resident Care Coordinator (RCC), (1) Med-Tech staff. Ombudsman was present when (2) residents were observed and attempted to be interviewed regarding recent bruising they sustained from unwitnessed falls. LPA reviewed resident files and incident reports submitted for each resident following an unwitnessed fall. The results of the investigation are as follows: The Department received an anonymous complaint on 7/10/23 alleging "there are two residents that have really big bruises on their face and one resident that got hurt". There were no details provided as to resident names, dates of injuries, or staff names or witnesses. The Department receivesd (2) incident reports on 7/11/23 for residents (R1 and R2) reporting bruises that were observed on each resident. **cont on 9099C(1)... Unsubstantiated 9099C(1).The incident report for R1 reports that resident had an unwitnessed fall on 7/6/23 (6:30 pm) in the hallway and sustained a large lump on her head and left side of her face. Resident was sent out to ER for further medical evaluation and returned the same day. Resident was placed on 48 hours alert charting. Care Plan was last updated 2/2/23 and notes resident needs escorts to meals and activities. Physician's report, dated 10/12/22, indicates resident is ambulatory but is a fall risk. Resident does not require 1:1 supervision. Interview with Administrator confirmed that resident was sent out for medical attention immediately following the unwitnessed fall. Interview with Med-Tech staff (S1) revealed S1 was not working on 7/6/23 (6:30 pm) when resident R1 had an unwitnessed fall. S1 stated that she/staff has been working with resident's medical provider regarding resident's medications, which have been "cut back about 35%". S1 indicated that resident won't sit in a wheelchair and tries to push the chair instead and confirmed that R1 has not had any subsequent falls and gets agitated with staff easily. LPA and Ombudsman observed R1 on 7/13/23 in her room at the community. Resident was standing up behind a wheelchair as if she was going to push it. Resident initially stated she was in pain but then said she was not and was not able to provide any details as to how the bruising occurred. The incident report for resident (R2) reports that resident was sent out to the ER on 7/9/23 (8:30 pm) after being evaluated by a hospice nurse and physician, due to bruising and swollen lips and eyes. Staff (S1) stated she was working at the facility on 7/9/23 (Sunday) when resident was sent out to the ER, explaining resident had a prior unwitnessed fall on 7/6/23, in the hallway and sustained bruising on her face/lip area. S1 stated she called hospice on 7/9/23 due to the bruises appearing worse than in previous days. S1 stated resident returned to the facility on 7/10/23, in the afternoon, asserting "R1 falls quite often" and she/staff and resident's son have been working with hospice to adjust resident's medications so that medications causing drowsiness are only taken during the evening hours. S1 confirmed that resident has not fallen since Monday, 7/10/23, prior to the medication changes made on Tuesday, 7/11/23. Both the Administrator and S1 confirmed there have been no other residents who have sustained any bruising in recent weeks other than residents R1 and R2, and they were both due to unwitnesed falls. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report to Administrator.the state’s words, verbatim · CDSS document, Jul 13, 2023 · control 59-AS-20230710094256

Allegation investigated: Staff are not adequately supervising a resident while in care.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint investigation for the above allegation. LPA met with Editha McCullough, Interim Administrator, and explained purpose of inspection. During today's inspection, LPA interviewed Interim Administrator, Resident Care Coordinator (RCC), and the Maintenance Director. LPA reviewed the incident report (LIC624) submitted to the Department on 6/30/2023 as well as resident (R1's) physician's report, care plan and other paperwork. The results of the investigation are as follows: Both the Administrator and RCC stated resident had just moved to the community on 6/29/2023 when he eloped later that evening, at approximately 7:30 pm. LIC624 states that resident was discovered missing by a med-tech who had entered resident's room to administer medications. All staff were immediately informed and began searching for the resident inside and outside of the community. ***cont on 9099C(1).. Substantiated 9099C(1)...RCC, who was not working at 7:30 pm, was contacted by facility staff and she went to the nearby gas station and surrounding area and learned that resident had asked for directions to the bus station. RCC located resident while driving down Antelope Rd and returned resident to the community at around 7:50 pm, uninjured. Resident stated to RCC that he "jumped the fence" in the outside patio area that faces the street. LPA reviewed resident's care plan that was updated on 6/29/2023 with additional notes added regarding wandering and elopement during the evening/sun downing hours. Physician's report, dated 6/26/2023, notes that resident is frequently confused and has increased agitation and confusion at night, due to sun downing, is not able to leave the facility unattended and needs constant medical supervision. Extra staff have been monitoring the resident during evening hours, and the resident has not tried to leave the facility again. Resident's family and physician were notified of the incident with a request that resident's medications be reviewed for a possible adjustment to the evening dosages. LPA observed the outside fence area where resident climbed over and observed an alarm on the patio door to sound when the door is opened. LPA spoke to Maintenance Director who confirmed that the batteries sometimes get low and they were replaced immediately following the incident on the (3) exit doors without a delayed egress alarm. Based on information obtained and reviewed, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview. Copy of report and appeal rights provided. 9099A-C(1)... LIC624 states that R3 was taken to the ER for further medication evaluation since it was an unwitnessed fall and was prescribed Lidocaine for a scalp laceration. 48 hour alert charting was initiated following the incident for R2 and for R3 upon return from the hospital. LPA interviewed the Ombudsman following her investigation of the incident on 7/3/2023. The Ombudsman discussed the incident with RCC who indicated she had viewed the video surveillance and was informed R3 fell and was not pushed by R2 and R3 did not sustain any substantive injuries. The Administrator and RCC confirmed there were (4) staff working on shift during this incident. Med-Tech was administering night time medications and the (3) care staff were assisting with putting residents to bed. It is common that while staff is helping some residents, there are other residents who are sun downing in the common areas. Based on information obtained, staff responded as quickly as they heard R3 yell, and staff was not able to prevent this isolated incident. LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report to Administrator.the state’s words, verbatim · CDSS document, Jul 6, 2023 · control 59-AS-20230629113804

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(j) · Plan of correction due date: Jul 7, 2023

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Based on interviews conducted and observation, the LIcensee did not ensure that the auditory device on the patio exit door was working effectively, on 6/29/2023 (7:30 pm approximately) , to alert staff that resident (R1) had exited the the building, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 6, 2023

Plan of correction: Maintenance Director stated on 7/6/2023 that the batteries in all (3) exit doors without a delayed egress alarm were replaced following the incident (AWOL) on 6/29/2023. Administrator and Maintenance Director agreed to place a second working alarm on each exit door so it can be heard by staff and also conduct a staff elopement drill. Documentation of a second alarm being placed on the door to be provided to the CCLD by 7/7/2023. Documentation of staff training for elopment drill to be provided to CCLD by 7/21/2023. Administrator stated she would discuss additional possible solutions with the Regional Director, including installing an outside camera on each patio, updating the pager system to include alerts from exit doors, use a Wanderguard bracelet on any resident(s) that has wandering tendencies.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced to deliver findings to an investigation conducted by the Department relating to an incident from 4/16/2023. LPA met with Editha Mc Cullough, Interim Administrator, and Ashley Stahl, Resident Care Coordinator, and explained purpose of inspection. The Department conducted an investigation into the above incident where resident (R1) was pushed by resident (R2) when (R2) entered (R1's) room at approximately 8:00 pm. (R1) was sent to the hospital following the incident and diagnosed with an L3 vertebral compression fracture. Hospital records show (R1) was admitted on 4/16/23 and was discharged on 4/20/23 to a skilled nursing facility and returned on 5/12/23. The Department conducted interviews with various staff, (R1) and family members and (2) other residents. (R2) was not able to answer the interview questions due to her cognitive diagnosis. All staff interviews concluded that R2 has never been aggressive towards other residents or staff prior to the said incident and (R2) regularly roams the memory care community and enters resident rooms. Interviews confirmed that staff did not witness the incident but were nearby in the lobby area and responded immediately upon hearing (R1) yell for help. Interview with (R1) revealed that prior to the incident on 4/16/23, (R1) did not have any concerns for his safety relating to (R2), as (R2) had never shown any aggression towards (R1). (R1) stated on 6/16/23 when interviewed by the Department that he feels R2 became upset and pushed him when he took the sock from her that she had taken from his dresser. R1's spouse (R3) who also resides at the facility, as well as (R1's) family member, expressed they did not have any concerns related to (R2) being aggressive towards (R1). The Resident Care Coordinator confirmed that a lock was installed on the door to (R1's) resident room that is able to be locked only from the inside and can be unlocked from either side. Based on information obtained, the Department was unable to establish that (R1) sustained a back injury due to lack of care and supervision by the facility and finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report left with Administrator.the state’s words, verbatim · CDSS document, Jun 21, 2023

Type of visit: Collateral

Licensing Program Analyst (LPA) Sabrina Calzada attended a meeting on 5/10/23 from 10:00- 11:00 am with the Ombudsman assigned to the facility, the supervising Ombudsman, and Robert Godfrey, Regional Director and Mark Cimino, CEO of the facility. The meeting was held at an office location for the facility due to a current Covid outbreak at the facility. LPA was invited to attend the meeting by the assigned Ombudsman since she is the assigned analyst to the facility. During the meeting, areas of recent concerns at the facility were discussed and noted, including staff reporting requirements and staffing levels. Information on Family Councils was provided by the Ombudsman who also offered to assist as needed to implement one at the facility. CEO stated the Regional Director is the first point of contact for the facility since he is most aware of the daily events at the facility. Regional Director agreed to provide additional documentation to the Department that was requested on 5/9/23 by LPA. There are no citations issued on this report. A copy of this report was written and emailed to the Regional Director for a signature at approximately 4:45 pm on 5/10/23.the state’s words, verbatim · CDSS document, May 10, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to an incident that occurred on 4/16/23 between residents (R1 and R2). LPA received an incident report on 4/17/23. LPA discussed the incident more with Administrator, Tina Prewitt. Current RCFE Administrator certificate shows Administrator's name as Tina D. Smith. LPA to change Administrator's name to Tina Newton-Smith. Administrator confirmed that resident (R1) remains hospitalized due to a back injury and may return with a brace. Administrator indicated that resident (R2) returned the same day with antibiotics for a diagnosed UTI. LPA attempted to speak with R2 during today's inspection, but R2 was observed to be sleeping. LPA obtained copies of paperwork from each resident's file and an updated LIC624 with the correct incident date. There are no deficiencies issued on this report. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Apr 24, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to an incident that occurred on 4/15/23 between residents (R1 and R2). LPA received an incident report dated 4/17/23 for the incident. LPA attempted to speak to resident (R1) in the presence of Administrator, but resident was not able to be understood but was in a pleasant mood. LPA did not observe R1 to show any bruises on her face or lower legs that were not covered by clothing. R1 was sitting in a wheelchair next to one of the glass exit doors, enjoying the outside view and/or sun. LPA observed R1 able to move herself in a wheelchair and Administrator confirmed that R1 is able to self ambulate in her wheelchair. Administrator stated that resident (R2) who was involved in the incident was taken to the emergency room for a mental evaluation on 4/15/23 and will not be returning to the facility due to changes in behavior from a recent stroke. Administrator confirmed that the Ombudsman's office was at the facility earlier this week also to follow up on the incident reported. There are no deficiencies issued on this report. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Apr 21, 2023

Allegation investigated: Resident sustained unexplained injuries while in care.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint report received on 1/18/2023. LPA met with Tina Prewitt, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols, was screened per Covid-19 precautionary measures upon entering the facility and wore the following Personal Protective Equipment (PPE): surgical mask. The results of the investigation are as follows: During the investigation, LPA interviewed the following facility staff: Administrator, Resident Care Coordinator (RCC), (2) caregiver staff, and (2) residents. LPA also interviewed (2) individuals who are employed by an outside health care provider. LPA reviewed facility documentation related to residents (R1 and R2) and medical documentation related to resident's (R1) injury referenced in the complaint report.. The results of the investigation are as follows: cont on 9099C(1)... Unsubstantiated 9099C(1).. Allegation: Resident sustained unexplained injuries while in care. Complaint alleges that resident (R2) yanked the necklace from around resident (R1's) neck which cut R1's left forearm. Resident (R1) moved to the community on 8/4/22. Resident (R1's) physician's report, dated 8/2/22 notes that resident has Mild Cognitive Impairment, is confused/disoriented, has wandering behaviors and occasional inappropriate behavior such as taking other people's belongings. The physician's report does not indicate R1 has a motor impairment; however, resident's current/initial care plan, dated 8/5/22, notes resident needs escorts to activities, meals and toileting and staff assistance with using assertive devices, including a walker and/or wheelchair, and monitoring due to non-compliance. Additionally, LPA observed R1 to use a walker to help with ambulation when interviewing her on 1/19/23. LPA interviewed resident (R1) on 1-19-23 and observed a larger sized Band-Aid to be on R1's left forearm. R1 stated to LPA that " the caregiver named Amelia tried to take a necklace from me and scratched me in the process", on 1-17-23. . R1 provided a physical description of how said caregiver wore her hair and dressed. R1 stated she noticed the cut on her wrist while on the bus, two days ago, and reported the cut to a nurse at the clinic who provided first aid care. R1 stated to LPA that she has fallen on two occasions before, stating "I fell in the dining room and slipped off my walker once before" and also "I slipped one time on the shower mat:. R1 indicated she does know a resident with the same first name as the staff person who allegedly grabbed her necklace from her neck. All staff interviews confirmed there is currently not a staff person who goes by the first name, Amelia. Administrator stated she was not aware of the cut on R1's left forearm until she returned from the health clinic on 1/17/23, and then at that point, she completed and submitted a report to the Ombudsman. HSD stated R1 doesn't have any history of skin tears on her arms and the "story keeps changing" about the alleged staff member who tore the necklace off of her. One caregiver staff stated that R1 " gets clumsy every now and then and can lose her balance and is wobbly" when walking. A second caregiver staff stated R1 didn't mention anything to her about the skin tear and she could have bumped herself stating "when she had a skin tear before, she would "mess with it" and R1 "will always bring it to staff's attention when she has an issue". cont on 9099C(2).. 9099C(2).. All staff interviews indicated that R1, and other residents, will enter other resident rooms and take things due to their cognitive diagnosis. Narrative charting notes for R1 document multiple instances of this behavior from September 2022- January 3, 2023. LPA interviewed resident (R2) on 1-19-23. R2's Physician's Report, dated 5-28-22, notes R2 has a diagnosis of Dementia but is able to follow instructions and communicate her needs. R2 stated she knows R1 and sometimes they watch television together. R2 stated she never tried to grab a necklace off of R1's neck., stating she has never observed R1 to wear any necklaces. R2 added, "I do see some people going in other people's rooms sometimes" so she asked her family members to take her valuable jewelry home. LPA contacted (2) individuals who work at R1's health care clinic. One of the individuals stated that she has only worked with R1 for a short time, but during that time, R1 mentioned an individual named "Amelia" on (3) occasions. Specifically, R1 stated that R1 was upset because Amelia "didn't put sugar on her rice". The same individual stated that she observed the scratch on R1's left forearm on 1-17-23 but does not have any information related to how it occurred. LPA spoke to a second individual at R1's health care clinic who is a medical professional. LPA reviewed a copy of the nurse's notes from 1-17-23, which state that R1 reported that a caretaker from the facility "yanked her necklace off of her neck and accused her of stealing it" and "when the necklace was pulled off, the metal part of the charm cut into (R1's) left fore arm". Clinic notes show that wound care was provided and a photo was taken and forwarded to the clinic Nurse Practitioner (NP) as well as a follow up appointment scheduled for R1 for later that week. Additional notes state that per the opinion of the NP, the wound is not consistent with R1's reports but that the wound is consistent with a "bump" injury. NP stated that It looks to her as thought the participant bumped her left forearm on something and the skin tore. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report left with Administrator.the state’s words, verbatim · CDSS document, Feb 23, 2023 · control 25-AS-20230118102646

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Tina Prewitt, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols and was screened per Covid-19 precautionary measures upon entering the facility and was wearing a surgical mask. The facility is licensed for 48 non-ambulatory residents who have a diagnosis of Dementia, 8 of whom may be bedridden, and has a hospice waiver for 17 residents. There are currently 7 residents on hospice. LPA to provide an updated copy of the facility license to reflect the approved hospice waiver. LPA, Administrator and Maintenance Lead, toured the interior and exterior of the facility including the common areas, (2) resident rooms, medication room, dining rooms, activity room, salon, kitchen and staff lounge. LPA observed the facility to be clean, in good repair, odor free and the bathrooms to have paper towels, soap, trash cans with lids. LPA observed a 20-second hand-washing poster above each bathroom and kitchen sink. Fire extinguishers observed throughout and to have last been serviced on 6/1/2022. All exit doors and front entrance door are equipped with an egress door alarm. LPA observed hand sanitizers in the common area. There is an enclosed courtyard with seating for residents. LPA observed the inside temperature to be 72-74*F. LPA observed 2+day perishable and 7+day non-perishable supply of food in the kitchen and the refrigerator/freezer temperatures to be recorded daily. Fire Dept conducted an annual exam on/around November 2022 and everything was found to be in compliance. LPA observed an abundant supply of all types of PPE and incontinent products on site. LPA observed required postings and Covid posters as well and was advised the RCFE Administrator certificate has been renewed. All staff is cleared and associated. Administrator to review and updated roster as needed. Discussed current vaccination status of residents and staff and eligibility for newest Booster. Booster flyers provided. Discussed recent PIN 23-02 issued 2-9-23 providing an update on testing, isolation, quarantining and masking. LPA obtained a copy of LIC308 and current liability insurance during today's inspection. LIC500 to be provided by 3/2/23. There were no deficiencies observed during today's inspection. Exit interview. Copy of report left.the state’s words, verbatim · CDSS document, Feb 23, 2023

Allegation investigated: Resident sustained unexplained injuries while in care

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver investigative findings to a complaint received on 9/19/2022. LPA met with Tina Prewitt, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols and was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE): surgical mask. During the investigation, the Department interviewed multiple facility staff members, residents, including resident (R1), as well as several individuals who had knowledge related to the allegation. In addition, the Department reviewed resident's (R1) documentation on file at the faciltiy and hospital medical records. The results of the investigation are as follows: cont on 9099C(1)... Unfounded 9099C(1)....Resident (R1) was sent to the emergency room on 9/17/2022 due to an "Altered Mental State" and was admitted to the hospital that day. While receiving further medical evaluation, doctors observed "8-10 small petechiae type bruises on the inside of her labia. " The area of the petechiae was alarming and was reported by medical staff. It was later discovered that the cause of the petechiae was a medical condition which causes swelling and irritation to the skin known as "Lichen Planus" and "Pruritis" which causes itchy skin. The local police department conducted their own preliminary investigation which included a SART exam. No foreign DNA was found in resident's vaginal area. Due to no medical evidence being found, it was determined the petechiae was self-inflicted, and the case was closed as "unfounded". Several staff members were interviewed. All interviews concluded that R1 is a 2-person assist with all ADL's and requires (2) staff to assist with providing incontinent care. All staff interviewed stated that no staff member witnessed anyone clean R1 inappropriately and confirmed they are trained mandated reporters and they must report any sort of abuse immediately. Several residents were interviewed or attempted to be interviewed. Residents who were able to communicate their thoughts indicated that the facility is a good place to live, staff take good care of them and they were not aware of any abuse towards other residents taking place. Some residents interviewed were not able to provide any information due to a diagnosis of later stages of Dementia. Based on information obtained through interviews and medical documentation, there is no evidence to support resident's bruising was caused by sexual abuse. Per R1's medical records, the petechiae was caused due to a medical condition; therefore, the allegation is UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Dec 22, 2022 · control 25-AS-20220919142458

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 04/07/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator - Tina Newton , and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility to complete a facility risk assessment. LPA wore the following Personal Protective Equipment (PPE) during today's visit: surgical mask. LPA were screened by facility staff before entry to facility. LPA and Tina toured facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to: kitchen, common areas, four (4 ) bedrooms, two (2) bathrooms, laundry room, two (2) dining rooms, courtyard area and storage area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Tina completed the infection control domain together. No deficiencies are being cited as a result of today's inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Apr 7, 2022

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

LPAs Lusby and Bains arrived on Thursday December 16, 2021 to conduct a case management visit due to an incident report received by the Department on 12/7/2021. Prior to the visit, LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. LPAs discussed the unexpected death of R1 with Administrator. LPA obtained copies of R1's physicians report, emergency identification sheet, care plan, ISP, and medication list. LPA requested Administrator obtain a copy of R1's death certificate and fax to the Department. Exit interview conducted. A copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 16, 2021

Type of visit: Required - 1 Year

LPAs Lusby and Bains arrived on Thursday December 16, 2021 to conduct the annual inspection. Prior to the visit, LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. LPA and Administrator completed the infection control domain together. Facility was found to be in substantial compliance. LPAs, Administrator, and Maintenance Director completed a facility walk through. No health, safety, or personal rights violations were observed. LPA requested the following updated forms to be faxed to the office: LIC500, LIC610E, LIC308, and a copy of the current Administrator's certificate. Exit interview conducted. A copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 16, 2021

Allegation investigated: Staff did not provide adequate care and supervision to residents. Staff did not treat resident with dignity and respect.

On 12/3/2021, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for complaint # 25-AS-20210720093422. LPA met with Tina Newton, Executive Director, and explained the reason for the visit. Prior to initiating the visit, LPA completed the required COVID-19 Testing Protocols, and a daily self- screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and a mask was worn for Personal Protective Equipment (PPE). Additionally, LPA was screened by front desk personnel. Throughout the course of the investigation, the Department reviewed facility notes, conducted interviews with residents and staff, reviewed resident file, and obtained relevant documentation and evidence. LPA interviewed 5 staff and 5 residents who all report that they have never witnessed any residents to not have their needs met. All 5 residents report they have all their needs met and have never had any issues getting them met. In addition, no staff or resident has ever heard staff treating residents without dignity and respect. To continue see 9099 C... Unsubstantiated Based on interviews and observation and records reviewed, LPA has determined the allegation to be UNSUBSTANTIATED, which means, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED Per California Code of Regulations, no citations were issued. An exit interview was conducted and a copy of this report was given to Tina Newton.the state’s words, verbatim · CDSS document, Dec 3, 2021 · control 25-AS-20210720093422