Creston Village Assisted Living and Memory Care

Allegation investigated: Staff falsify records

At 9:20am, on 8/25/2026 Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to investigate the allegation of this complaint. LPA met with the Business Office Director Emma Perry, announced who he was and the reason for the visit. Administrator Adam Bramwell was not available due to being away for coorporate training. During today’s visit LPA conducted interviews and reviewed records. On the allegation, staff falsify records; it was alleged that the facility is using the signature of Person #1 (P1), a former employee, to obtain physician orders. Interviews and record review reveal P1 was employed as the Health and Wellness Director with their last date of employment at the facility as 4/18/2026. (Continued on LIC9099-C) Substantiated Staff interviews revealed that prior to admission the Sales Director provides a packet to the prospective resident’s family and/or primary care physician. The packet includes a cover sheet, Physician’s Report (LIC602A), resident orders, PRN authorization, orders for special diet, and a California Physician Orders for Life Sustaining Treatment (CA POLST). The cover sheet is one (1) page, lists the requested documents, and at the bottom of the page has a line for the names of both the Health and Wellness Director and Executive Director. LPA review of select resident records that have moved into the facility after P1’s last day and the original digital copy of the cover sheet on the Sales Director’s company computer have a digital signature of P1’s name and nursing degree of LVN above the line titled Health and Wellness Director. Above the line titled Executive Director in typed font is Adam Bramwell; Adam is the facilities designated Administrator as well. The PRN authorization page has fields for facility staff to complete requesting the form be completed by a physician. The fields include a signature and the staffs title. LPA review of select resident records that have moved into the facility after P1’s last day and the original digital copy of the PRN authorization form on the Sales Director’s company computer have a digital signature of P1’s name and nursing degree of LVN in the signature field and Health and Wellness Director in the title field. Interviews revealed that the Sales Director updates the digital signature on these forms when a new Health and Wellness Director is hired using PDF editing software. Staff stated they did not ask P1 for permission to place their digital signature on the form when they were updated but they recall verbally notifying P1 later that it was added and that P1 was responsible for reviewing the forms during their time at the facility. According to interviews P1’s name has not been removed since they left the facility because a new Health and Wellness Director has not been hired. Interviews and records indicate the facility has not hired a new Health and Wellness Director since P1 left and is still actively trying to fill the position. On 5/13/2026 the facility hired a Health and Wellness Coordinator who is a licensed vocational nurse. Staff stated that when the forms are received completed by a physician they are provided to the Executive Director/Administrator Adam Bramwell and Sangeeta Devi the Regional Vice President of Health and Wellness, who is a licensed vocational nurse, for review to determine if the facility can meet the needs of the potential resident. If the resident’s admission is approved these forms are provided currently to the Health and Wellness Coordinator to place in the resident’s paper file. The Regional Vice President of Health and Wellness states, “I do not always receive the cover sheet or PRN authorization form for review. I mostly focus on reviewing the LIC602.” (Continued on LIC9099-C) Record review reveals at least thirteen (13) residents currently residing in the facility were admitted after P1 left on 4/18/2026. Staff interviews revealed the forms with P1’s digital signature have been used for every admission during the four (4) months P1 has not worked at the facility. Although the staff may not have had ill intent by leaving P1’s digital signature on the forms, it is a misleading representation to the public of the staff currently employed at the facility having nursing certification. Additionally, this was not addressed during review of these documents by the Executive Director/Administrator, Regional Vice President of Health and Wellness, and the Health and Wellness Coordinator. Exit interview conducted, deficiency cited on LIC9099-D page, report signed, appeal rights and report provided to the Business Office Director.the state’s words, verbatim · CDSS document, Aug 25, 2026 · control 29-AS-20260819205105

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Sep 8, 2026

False Claims - No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply when they mislead the public by using a former employee’s digital signature and nursing certification on forms which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 25, 2026

Plan of correction: Regional VP Health and Wellness Director states they will work with the Administrator to create a written plan to ensure updated forms are used and the use of former employees identification is not used to conduct company business. The plan and updated forms will be emailed to LPA on or before 9/8/2026. Business Office Director present for creation of this POC.

Allegation investigated: Staff are not wearing gloves during diaper changes. Staff made an inappropriate comment to residents in care.

At 9:20am, on 7/7/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to deliver final findings to the allegations above. LPA met with Administrator Adam Bramwell, announced who he was and the reason for the visit. During a visit on 3/3/2026 LPA conducted interviews, toured select areas of the facility, and collected relevant documentation and on 7/2/2026 conducted additional interviews. On the allegation, staff are not wearing gloves during diaper changes; it is alleged that Staff #1 (S1) does not wear gloves when assisting residents with toileting needs and when handling food. (Continued on LIC9099-C) Substantiated Interviews revealed that multiple staff members have recently observed S1 providing resident care, including toileting and brief changes, without wearing gloves, with incidents reported as recently as March 2026. Staff also reported that S1 does not wash their hands in between providing care and that they have not observed S1 wash their hands prior to handling resident food. Several staff stated that they have offered S1 gloves or asked them to wear gloves during care tasks, but S1 declined, stating they did not need to use them. Staff reported that gloves of all sizes are available and are stored in the staff room on the first floor of assisted living and in the memory care kitchen area. Staff acknowledged they wish the facility had additional glove locations. Due to limited locations, staff often carry extra gloves in their pockets to avoid walking back to supply areas. S1 admitted that there have been times they have provided bathing and toileting care without wearing gloves, stating this occurred when the correct glove size was not immediately available. S1 also admitted they were not wearing gloves while plating food for residents in memory care until they were instructed to do so during a recent training. A review of S1’s personnel file revealed that they were counseled in February 2026 for not properly wearing gloves during resident care. Records further show that S1 received additional training in March 2026 from the Health and Wellness Director regarding proper glove use. The Administrator confirmed they were aware there had been issues regarding S1’s glove use but did not recall whether formal disciplinary action had been taken. The facility’s Plan of Operation states that all staff must maintain infection control practices, including hand hygiene and the use of gloves as protective barriers to prevent infection transmission. It further specifies that personal protective equipment (PPE) must be used during direct care tasks, including bathing and incontinence care. Staff confirmed they receive online video training that includes instruction on when PPE is required. Based on all interviews conducted and documents obtained, S1 did not wear gloves as required and at this time the above allegation was found to be substantiated, there is a preponderance of the evidence to prove that the alleged violation occurred. (Continued on LIC9099-C) On the allegation, staff made an inappropriate comment to residents in care; it is alleged that S1 makes undignified comments to residents in care. It is also alleged that on one occasion a resident expressed desire to go to their home and S1 stated they could not go home because there are cleaning materials in their home that could cause them to die. Interviews revealed multiple instances of inappropriate communication by S1. One witness observed S1 sitting in the memory care unit looking at their personal phone while a resident repeatedly asked S1 if they could use their phone to call their spouse. The witness reported that S1 responded in a firm tone, stating to the resident that their spouse was dead and therefore could not call them. On another occasion, a witness observed a resident stating they wanted to go home. The witness reported that S1 got close to the resident’s face and raised their voice, stating that the resident could not go home because the house was being fumigated and they would die. The witness clarified that S1’s tone was not raised for the resident to hear because this resident was not hard of hearing, but that S1’s voice was aggressive in nature, and after the interaction the resident became visibly anxious and tearful. A different witness reported an incident in which a resident attempted to get up from their chair during a meal to use the restroom. S1 reportedly told the resident, in an aggressive tone, that they could not go because they had not finished eating and that they should go to the bathroom in their brief instead. During interview, S1 acknowledged that staff and residents have told them they sound aggressive when they speak, and they said they do not know how to correct this. S1 stated they used to tell residents the truth about situations such as informing them that their spouse had died, but denied intentionally being aggressive. Witnesses also stated they have observed S1 grab residents in a rough manner. Witnesses additionally reported an incident in March 2026 involving Resident #1 (R1). Staff found R1 sitting on the floor in the memory care kitchen area. S1 was reportedly on their personal phone in the dining room in a position where they should have been able to observe R1. When staff checked on R1, the resident was unresponsive to verbal cues. Staff asked S1 to assist them with R1 and when S1 came over they kicked R1’s leg, causing the resident to say “ow.” (Continued on LIC9099-C) Later, after R1 was placed in a chair and again appeared unresponsive, witnesses observed S1 repeatedly pinching R1’s nose closed. Staff state that R1 appeared to have irregular breathing and was not breathing through their mouth as their mouth was closed. Staff are not sure why S1 did this and they asked S1 to stop multiple times. Staff interviews revealed they are trained to gently attempt to get a resident to respond either verbally or by physically rubbing their shoulder, arm, or leg, not by pinching their nose shut. S1 stated they did not recall pinching R1’s nose and believed they may have placed their hands on R1’s cheeks. S1 also stated they used their foot to move R1’s leg to create space to assist in lifting R1 from the floor. S1 said they did not recall R1 responding when they moved R1’s leg. S1 further stated that they later learned they should not have moved R1, but believed they were following the med-tech’s direction at the time. Multiple witnesses reported they had informed the Administrator and the Health and Wellness Director about these incidents involving S1 but did not feel the concerns were addressed. A review of S1’s personnel file revealed a typed note indicating that S1 does not appropriately redirect residents, does not do so professionally, speaks to residents in a manner perceived as mean, and does not remain calm. The note states that S1 needs additional training. No disciplinary action or follow-up training was documented. The Administrator stated they were unaware of the note until reviewing the file during this investigation. The Administrator explained that minor issues are typically handled by department managers, and they only become involved if issues escalate or reoccur. The Administrator recalled that when S1 first started, some residents in assisted living had concerns about S1 but not regarding the way they spoke to them or treated them. The Administrator recalls the previous Health and Wellness Director briefly mentioned something about the way S1 spoke to the residents but understood that they were handling it. The Administrator does not recall further concerns being brought to their attention. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be substantiated, there is a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, deficiencies cited on LIC9099-D pages, report signed, appeal rights and report provided to the Administrator. Interviews revealed no firsthand observation of S1 sleeping in any resident’s room. No witnesses confirmed personally seeing S1 asleep in a resident’s bed or elsewhere in resident rooms. S1 denied ever sleeping in resident rooms. During the investigation, multiple staff reported concerns unrelated to sleeping. Staff stated that S1 spends a significant amount of work time on their personal phone, leaving other staff to perform resident care and assigned tasks. Staff reported that although S1 will assist when asked, S1 often remains distracted by their phone, including while helping coworkers. A review of S1’s personnel file revealed that S1 has been counseled on three separate occasions for excessive personal phone use while on duty: in October 2025, December 2025, and March 2026. Based on all interviews conducted, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Technical assistance was provided and LPA reviewed with the Administrator the impact that distracted staff for extended periods of time can have on the care and safety of residents. Exit interview conducted, report signed, and report provided to the Administrator.the state’s words, verbatim · CDSS document, Jul 7, 2026 · control 29-AS-20260225145026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(a)(4)(A)(3) · Plan of correction due date: Jul 21, 2026

(a) A licensee shall ensure that infection control practices are maintained as follows: (4) All facility staff...shall use gloves...as specified below. (A) Gloves shall always be worn when: 3. Assisting with direct resident care... This requirement was not met as evidenced by: Based on interview and record review, the licensee did not ensure S1 wears gloves per regulation and the facilities plan of operation which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: Administrator states they will provide the next level of corrective action to S1. Administrator also states that on 7/1/2026 training was provided to care staff on when to wear gloves/PPE. Administrator will email LPA training minutes, signed staff roster and corrective action taken for S1 on or before 7/21/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jul 21, 2026

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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not ensure S1 treated residents with dignity and respect which posed a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: Administrator states there will be corrective action taken for S1. Administrator states during the all staff meeting scheduled for tomorrow 7/8/2026, they will include resident rights including treating them with dignity and respect. Administrator will email LPA training minutes, signed staff roster and corrective action taken for S1, on or before 7/21/2026.

Type of visit: Case Management - Incident

At 9:20am, on 7/7/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct a Case Management – Incident visit. LPA met with Administrator Adam Bramwell, announced who he was and the reason for the visit. On 2/27/2026 at 11:43 p.m., the Administrator emailed the LPA to report that, during an audit conducted earlier that day by Omnicare pharmacy staff, multiple bottles of liquid narcotic medications were found to be missing. The Administrator stated that a full investigation was underway with the involvement of local law enforcement. On 3/2/2026 at 10:20 a.m., the LPA spoke by phone with the Administrator and the previous Health and Wellness Director about their internal investigation. They reported that eight (8) bottles of liquid narcotic medication were missing from the locked medication refrigerator in the medication room located on the first-floor. These medication bottles are kept inside their original packaging box with the pharmacy label. According to their investigation, a hospice nurse managed medications for two of the residents with missing medications and confirmed they observed the two medication bottles they managed were present on 2/26/2026 at around 11:00 a.m. Later that same day, at about 7:00 p.m., Staff #2 (S2) checked all eight medications for refill needs and confirmed that all eight bottles were present in their labeled boxes. On 2/27/2026 at about 11:00 a.m., Omnicare pharmacy staff discovered that the eight bottles were missing during a scheduled audit. The boxes with pharmacy labels were still in the refrigerator, but the medication bottles were not inside. At approximately 4:00 p.m. that day, the Administrator contacted local law enforcement. (Continued on LIC9099-C) During a visit conducted by the LPA on 3/3/2026, the LPA conducted interviews and collected documentation, including med management documents. LPA later obtained police reports. LPA interviews and record review revealed that the facility has a policy requiring narcotic counts at each medication technician (med-tech) shift change, typically at 6:00 a.m., 2:00 p.m., and 10:00 p.m. Three medication carts are used in the facility, and each cart is typically assigned to a different med-tech per shift. During narcotic counts, outgoing med-techs confirm the presence of each narcotic in their assigned medication cart with incoming med-techs and document this on the facility’s “Controlled Substances Shift Change Count-Check-Sheet.” This count includes the liquid narcotics stored in the medication room refrigerator. Liquid narcotic medications for all three carts are stored together in the same refrigerator, and med-techs are responsible for verifying the medications assigned to their cart. Staff reported that during the narcotic counts conducted on 2/26/2026 and on 2/27/2026 at 6:00 a.m., they did not check to ensure all the bottles were physically in the boxes. Interviews also revealed that during the 6:00 a.m. narcotic counts on 2/26/2026 and 2/27/2026, Staff #1 (S1) was acting unusually, attempting to rush the counting process and stating they needed to be somewhere. A routine medication audit had been scheduled for the morning of 2/27/2026 to be conducted by Omnicare pharmacy, which supplies most resident medications. During the audit, at approximately 11:00 a.m., Omnicare staff discovered the eight (8) bottles of liquid narcotics were missing. The eight (8) missing medications are two (2) bottles of liquid lorazepam 2mg/mL (one bottle had approximately 24mL left and the other unused at 30mL) and two (2) bottles of liquid oxycodone 30mg/mL (one bottle had approximately 24.75mL remaining and the other unused at 30mL) belonging to Resident #1 (R1); two (2) full bottles (30mL) of liquid lorazepam (2mg/mL) belonging to Resident #2 (R2); one (1) open bottle with approximately 28.75mL remaining of liquid lorazepam (2mg/mL) belonging to Resident #3 (R3); and one (1) open bottle with approximately 27.5mL remaining of liquid lorazepam (2mg/mL) belonging to Resident #4 (R4). (Continued on LIC9099-C) At approximately 11:30 a.m., the previous Health and Wellness Director notified the Administrator, who instructed staff to verify that the bottles were in fact missing. Interviews revealed that by the 2:00 p.m. shift change the medications had been confirmed missing, law enforcement had not yet been contacted, and med-tech staff did not want to conduct another narcotic count until the missing medications were reported to law enforcement. Interviews revealed that the Administrator did not get directly involved until this point. Administrator states that when they were notified of the missing medications they were caring for a short staffed kitchen since it was lunch time and wanted to ensure an internal investigation was conducted to make sure the medications were indeed missing before notifying local law enforcement. They were in communication with the corporate office notifying them of the missing meds and had additional administrative tasks to handle, a management position interview and resident care meeting. Records show that at approximately 4:00 p.m., the Administrator contacted local law enforcement. Staff stated that on the night of 2/27/2026 to 2/28/2026 there were three staff there that night a care staff in assisted living, a care staff in memory care and a med-tech. Witnesses stated that at approximately 1:00 a.m. on 2/28/2026, S1 arrived at the facility, they were not acting themselves, and asked the other staff for the medication cart keys. Staff did not provide S1 the keys and asked S1 to go home, but they stayed. S1 was also reportedly focused on a small brown bottle in the med-tech room labeled nitroglycerin. Staff removed the bottle from S1, and it was later discovered to contain eleven (11) clonazepam 2mg tablets. Staff stated that S1 did not attempt to harm anyone or perform resident care; however, during the shift, S1 began slurring their speech, became unsteady, and eventually fell asleep in a chair outside the med-tech room. At approximately 7:00 a.m., staff notified the Health and Wellness Director that S1 was asleep in the chair and could not be awakened. At approximately 7:45 a.m., the Health and Wellness Director contacted local law enforcement. When law enforcement arrived, S1 had awakened and was in the memory care unit of the facility. Law enforcement escorted S1 out of the facility and it was later determined that S1 was in possession of the missing medications. Exit interview conducted, deficiencies cited on LIC809-D pages, report signed, appeal rights and report provided to the Administrator.the state’s words, verbatim · CDSS document, Jul 7, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(25) · Plan of correction due date: Jul 8, 2026

Personal Rights (a) Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (25) To protection of their property from theft or loss... This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited when S1 stole multiple resident’s medications including narcotic medications, which posed an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: Administrator states S1 has not returned to the facility since 2/28/2026 and their continued employment is dependent on the outcome of this and law enforcement investigations. The locks on the med-room and refrigerator have been changed. The facility changed their policy to only store... liquid narcotic medications that a resident is actively taking. The Administrator states they will review the theft and loss program at the the next all staff meeting on 7/8/2026 and email the LPA the meeting minutes and staff roster on or before 7/10/2026.

Allegation investigated: Staff do not maintain a clean/sanitary facility

At 9:25am, on 3/25/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to deliver final findings to the above allegation of this complaint. LPA met with Administrator Adam Bramwell, announced who he was and the reason for the visit. During a previous visit to the facility on 01/06/2026, LPA toured the facility, interviewed staff, residents, the administrator, and obtained relevant documents. On the allegation, staff do not maintain a clean/sanitary facility; it was alleged that on a day in October 2025 Resident #1’s (R1’s) bathroom had feces on the toilet and walls. (Continued on LIC9099-C) Substantiated During LPA visit on 1/6/2025 LPA and Administrator Adam Bramwell toured the facility noting R1’s bathroom with yellow and brown dried substances on the toilet seat, brown dried spots on the bathroom floor, and the bathroom had a strong urine and fecal odor. Additionally in R1’s room multiple kitchenette cabinets had dried substances on the inside shelving, one drawer had a large spot of orange liquid spilled in it, another drawer contained a stained brown decorative pillow, the sink had dried food debris in it, and in the cabinet under the sink drainpipe the wood was stained, warping, and had multiple light grey, dark grey, and black spots. Upon inspecting all of the rooms in the Connections Neighborhood, memory care unit, the LPA and Administrator observed three additional resident rooms with grab bars, light switches and toilet seats with dried yellow and brown substances, all having a strong urine/fecal odor. Multiple stains were noted in the public hallway carpet in memory care with staff interviews revealing one of the carpet stains, brown in color, to be feces. Interviews revealed multiple staff had reported that specific stain to leadership on 1/5/2026. LPA photographed all the mentioned areas. Based on observation and all interviews conducted, at this time the above allegation was found to be substantiated, there is a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, deficiencies cited on LIC9099-D page, report signed, appeal rights and report provided to the Administrator. LPA review of R1’s record revealed R1 is diagnosed with dementia, struggles to communicate, has a contracted hand, is a one staff assist when toileting, has a private bedroom, and has a history of urinating in various spots of the facility. Regarding R1's toileting needs. Staff stated R1 will take themself to use the bathroom if the staff are helping other residents, R1 has a history of putting their hands in their feces, and staff monitor R1 for hygiene because of this. Staff are not aware of a recent time R1 had feces on their hands. Regarding R1's clothing, interviews revealed R1 will sometimes remove their pants independently, they will attempt to help R1 put the clothing back on, and there have been times when R1 has removed their pants, were sitting in their private room, and staff have offered R1 a blanket to cover their legs. Regarding R1's over-grown fingernails, staff interviews revealed they are not allowed to cut finger or toenails, but once month or every two months a podiatrist visits the facility, the facility has a beauty salon that residents or their responsible person can make appointments for them to have their nails cut, and care staff document on each residents shower sheet if they notice the need to have their nails cut. Staff also stated that due to R1's contracted hand it is difficult to open the hand for the nails to be cut, R1's family has been taking them out of the facility to have their nails cut on a regular basis, and currently a home health nurse has been monitoring and cutting the nails on the contracted hand, but the nurse is not always successful. Based on interviews and record review R1 does require assistance with their toileting, dressing and nail care needs and that the facility, home health, and R1's family are making efforts to provide R1 the care they need. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, report signed, and report provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 25, 2026 · control 29-AS-20251230091104

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 8, 2026

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 was not met as evidenced by: Based on observation and interview, the licensee did not ensure the facility was clean and sanitary which poses a potential Health, Safety, and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 25, 2026

Plan of correction: Administrator has already started checking the memory care unit more often for cleaniness and will conducted in-service training with staff on cleaning and sanitization of the facility and submit training documents and signed staff roster to LPA on or before 4/8/2026.

Type of visit: Case Management - Other

On March 3, 2026 at 9:00am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to conduct a case management - other visit to the facility. LPA met with Administrator Adam Bramwell and explained the purpose of the visit. On February 27, 2026 Administrator notified LPA via email that an audit conducted that day discovered missing medications. On March 2, 2026 LPA interviewed the Administrator and Wellness Director over the the phone for further details. During today's visit LPA gathered documentation, conducted interviews and toured select areas of the facility. No deficiencies issued during today's visit. LPA will return at a later date to conclude the investigation and issue citations. Exit interview conducted, report signed, and report delivered to the Administrator.the state’s words, verbatim · CDSS document, Mar 3, 2026

Type of visit: Required - 1 Year

On 1/6/2026, at 9:15am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced to this facility to conduct the annual inspection. LPA met with facility Administrator Adam Bramwell, announced who he is and the reason for the visit. At approximately 10:00am, Administrator and LPA conducted a full facility walk through and tour. This is a two story facility with a section dedicated to memory care on the first floor. The facility is square in shape with an outdoor courtyard in the center and one wing off to the south-east. LPA noted upon entering the main entry a lobby with reception desk to the left; an entrance to the large communal dining room across from the main entry doors; and a resident snack bar, the main kitchen, staff laundry room, staff room, maintenance room and employee entrance are to the right. The communal dining room has a smaller banquet room for small private events. On the first floor past the reception desk are administrative offices, a gathering/activity space (with piano, fishtank, and self-contained fireplace for residents and visitors to enjoy), 32 resident rooms with en-suite bathrooms, medication room, a dedicated activity room, public restrooms, laundry room and maintenance/housekeeping closets locked for resident safety. The memory care unit is separated by coded egress doors with an additional 15 resident rooms that have en-suite bathrooms, multiple activity rooms, a dining room and a fenced outdoor area with tables and shade for residents and visitors. LPA noted meals are delivered from the main kitchen to the memory care unit and served from the memory care kitchen. On the second floor there are 49 resident rooms with en-suite bathrooms, physical therapy room, laundry room, snack bar area with seating, beauty shop, and a TV/activity space. LPA inspected a sample number of resident rooms and noted that the rooms had working lights, ample storage, working appliances and non-skid surfaces in the showers. LPA noted an emergency evacuation chair located at the top of the five stairwells and the elevator was serviced on 12/24/2024. (Continued on LIC809-C) The facility exterior has a walking path around the entirety of the facility and an outdoor courtyard in the middle of the facility which also has tables and shade. There is a designated smoking area just outside the west side of the dining-room. The facility has wired/battery operated dual smoke/carbon monoxide detectors in each resident room and smoke detectors in the hallways tested by Alpha Fire on 8/6/2025. LPA observed fire extinguishers throughout the facility tagged current and in the green compression range, being serviced during todays visit. LPA tested facility hot water at various locations measuring between 109 & 112*(f), within regulation temperatures 105*-120* (f). LPA noted that the facility has no obstructions in hallways, doorways or exits. Medications are locked in medication carts. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication and Destruction Records. Administrator and LPA conducted a partial review of the facility annual CARE tools module. LPA will need to return to finish the annual. At this time no deficiencies are being cited. Exit interview, report read, and report provided to the Administrator.the state’s words, verbatim · CDSS document, Jan 6, 2026

Allegation investigated: Staff do not ensure that resident's incontinence needs are being met. Staff do not ensure that residents are assisted with bathing. Staff do not respond to resident's call for assistance. Staff are not assisting residents with medications in a timely manner. Staff did not respond to resident's fall.

At 1:20pm on 03/11/2025, Licensing Program Analysts (LPA’s) Jeffries and Haner-Tomasko arrived unannounced to deliver the final findings to all the allegations to this complaint. LPAs also conducted a subsequent case management visit on a report not related to this complaint during the same visit. LPAs met with Administrator, Adam Bramwell, announced who they are and the reason for the visit. As to the allegations of, “Staff do not ensure that resident's incontinence needs are being met.” and “Staff do not ensure that residents are assisted with bathing. “ It was alleged that Resident 1’s (R1) hair, and clothes were covered in own fecal matter and incontinence was not regularly changed by facility staff. It was discovered through observation and interviews on 11/21/2024 LPA Jeffries conducted a physical tour of facility memory care unit. LPA observed R1’s room to be clean and free of odor. LPA also attempted to interview R1 on 11/21/2024 however R1 interview did not result in a response to any of the questions asked. LPA also toured 4 resident rooms next to and across from R1’s rooms all clean in good repair and no odor. On 01/23/2025 LPA conducted a second physical inspection of R1’s room and person and noted no CONTINUED on LIC9099-C Unsubstantiated obvious neglect of incontinence care. On 01/21/2025 LPA Jeffries conducted interviews with Staff 1 – 4 (S1, S2, S4, S4) all stated that R1 has incontinence issued with “digging” and are always addressed by staff when observed and as needed. LPA reviewed facility care plan for R1 that shows two showers per week. At this time there is not enough evidence to support the allegations of. “Staff do not ensure that resident’s incontinence needs are being met.” And “Staff do not ensure that residents are assisted with bathing. “ both are unsubstantiated at this time. As to the allegations of, “Staff do not respond to residents call for assistance.” and “Staff are not assisting residents with medications in a timely manner. “It was alleged that R2 was yelling “Help me” and no staff responded. It was discovered through documentation, observations, and interviews that on 11/21/2024 LPA conducted a physical tour of facility and observed R2 in their room. R2 was vocal during the LPA observation stating “lord help me” LPA observed S4 attending to R2’s needs. On 11/21/2024 LPA Jeffries conducted an interview with S4 who stated that R2 baseline is continually requesting staff assistance by calling out or yelling for staff. S4 stated that Staff check on all residents, including R2 approximately every 15 minutes or less. Interviews on 11/21/2022 with S1, S2, S3, and S4 all stated that residents are continually checked for any changes in conditions of residents. All stated they have high confidence in all staff and no staff are neglecting residents needs. On 11/21/2024 LPA Jeffries attempted to interview R1, R2, R3, and R4 all stated they feel safe in facility, however none answered screening questions when LPA was checking cognitive understanding. On 11/21/2024 LPA Jeffries reviewed R1 and R2’s Physicians reports, Centrally Stored Medication Records (CDMR), and Medication Administration Records (MAR)and found no abnormalities. At this time there is not enough evidence to support the allegations of, “Staff do not respond to residents call for assistance.” and “Staff are not assisting residents with medications in a timely manner. “ and are both unsubstantiated at this time. CONTINUED on LIC9099-C As to the allegation of, “Staff did not respond to resident's fall.” It was alleged that approximately between October 28 through November 3 of 2024 an unknown resident had fallen, and no staff assisted the resident. On 11/20/2024, 11/21/2024, and 11/23/2024 LPA Jeffries attempted to contact the reporting party (RP) by phone with no answered. As of 03/10/2025 there has been to return call from RP. On 11/21/2024 and 11/27/2024 LPA Jeffries reviewed facility serious incident reports (SIRs) which reviled the following: On 10/25/2024 a resident fell in their room, pressed pendant and staff address fall; accordingly, there was no other recorded resident fall in the time period of the alleged fall and there were no subsequent reports of resident injury within that time frame of the alleged fall. At this time there is not enough evidence to support the allegation of, “Staff did not respond to resident's fall.” and is unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Mar 11, 2025 · control 29-AS-20241120103550

Type of visit: Case Management - Incident

On 03/11/2025 at 1:20pm, Licensing Program Analysts (LPAs) Haner-Tomasko and Jeffries conducted an unannounced Case Management visit. LPAs arrived at the facility, met with Administrator Adam Bramwell, and announced the purpose of the visit. During the investigation, LPAs reviewed relevant documents and interviewed staff and resident. On 03/03/2025, Community Care Licensing received a self-report from the facility regarding missing medication. On 03/03/2025, Resident #1(R1) reported medications missing from their self-managed medications to Administrator Adam Bramwell. On 03/03/2025, Adam reported the incident to Community Care Licensing, the Local Long-Term Ombudsman, local law enforcement, and opened an internal investigation. R1 is able to self-administer their medication, and keeps their medications locked in their apartment. It was alleged the narcotic Norco was missing, due to R1 keeping records of the number of pills in the bottle. The report states R1 believed 35 pills went missing in February 2025. On 2/27/2025, R1 left 3 Norco pills in a bottle at their bedside, went to dinner, and returned to find only 1 pill left. The facility was notified of the missing medications on 3/3/2025. On 3/8/2025, Administrator submitted a supplement incident report with additional details. After discussion with R1 and R1’s responsible parties, a Ring camera was placed in R1’s room to view only the drawer where the medications were kept and posted a camera in use sign outside resident room. On 3/5/2025 around 4:20pm, R1 left their room to go to dinner. At 5:25pm, the Ring camera detected movement in the room. The video footage revealed Staff 1 (S1) open the drawer, appear to take pills from the bottle, and exit the apartment within 20 seconds. The Administrator viewed the footage and contacted law enforcement. Once law enforcement was on-site, the pill bottles were collected and examined, and was found to be missing 2 Norco pills. Law enforcement questioned S1, who initially denied taking the pills. (Continue 809-C) S1 emptied their pockets and the 2 Norco pills were found on their person, along with 28 other pills of varying shapes, sizes, colors, and imprint codes. S1 refused to state where the other pills came from. S1 was arrested by law enforcement. S1 was terminated by the facility and administrator submitted documentation to remove S1's associated clearance from facility roster. Administrator stated they conducted an additional audit to ensure all residents who self-store medication had proper locking boxes. LPA recommended conducting an audit of all resident self-stored and administered medications with residents present. LPA conducted a medication audit of 9 centrally stored residents’ narcotic medications and found (no errors/errors). Administrator conducted full medication audit of all residents’ centrally stored medications on 3/6/2025. The following deficiencies were observed and cited from the California Code of Regulations, Title 22. Personal Rights of resident, property was not safeguarded by the facility. Exit interview conducted. A copy of the report and appeal rights issued at the time of the visit.the state’s words, verbatim · CDSS document, Mar 11, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(25) · Plan of correction due date: Mar 12, 2025

Personal Rights 87468.2....residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To protection of their property from theft or loss... This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited when S1 stole R1’s medications, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 11, 2025

Plan of correction: S1 was terminated 3/5/25. Administrator will create a policy addressing the residents self-custody of medication and training to review with every new and current resident who self-store medication, and as needed moving forward. The proposed policy will be emailed to LPA on 3/12/2025. A full medication audit of centrally stored medications was conducted on 3/6/2025. Administrator will email LPA documentation from the audit on 3/12/2025. Administrator will review facilities... (Continued LIC812).

Allegation investigated: Staff inappropriately restrained resident. Staff are not safeguarding resident's personal belongings. Staff are not ensuring resident is showered. Staff left resident in soiled diapers for extended period of time.

At 9:00am on 01/23/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to issue final findings to the allegations above to this complaint as well as to conduct facility annual inspection on a separate report. LPA met with Administrator, Adam Bramwell, announced who he is and the reason for the visit. As to the allegation of, “Staff inappropriately restrained resident.” It was alleged that an unknown date in September 2024, Staff 1 (S1), S2, and a third unidentified staff (S3) held down Resident 1 (R1). It was discovered through interviews and documentation that in interviews by Licensing Program Analyst (LPA) Jeffries, on 09/16/2025, with S1 and S2. It was discovered that R1 had had assistance with manicuring R1’s fingernails in September of 2024 by S1 and S2. Both S1 and S2 denied restraining R1 during the assistance with manicuring R1’s fingernails. S1 stated that, we both (S1 and S2) assisted R1 but no one had to restrained (R1) in doing so.” S1 did not recall who the third staff was nor a third staff assisting in the manicure of R1. S1 stated that R1’s right hand is always in a closed fist and S1 and S2 cut the nails of R1’s left hand, they attempted to cut the nails of R1’s right hand but R1 resisted. CONTINUED on LIC9099-C Unsubstantiated In an interview with R1 on 09/16/2024 by LPA Jeffries, R1 did not recall staff restraining R1 at any time. R1 stated that they have lived at the facility “for years”. R1 stated that they feel safe with staff and care at this facility. On 01/22/2025, LPA conducted a phone interview with R1’s Responsible party (F1). F1 stated that R1, had an undiagnosed stroke sometime in R1’s past (as told by R1’s Physician, Dr. Bettencourt) which resulted in R1’s right hand being closed. F1 stated that facility staff attempted to cut R1’s fingernails on the right hand but did not force R1. On 09/16/2024, LPA Jeffries conducted interviews with S4, S5, and S6, and all staff stated that they have never participated or have witnessed a restraint of any resident at this facility. On 09/16/2024, LPA Jeffries conducted interviews with R2, R3, R4, and R5, all stated that they have never been or seen any type of resident physical restraint at this facility. All four Residents stated that they feel safe in this facility and all staff treat them with dignity. LPA conducted a record review of incident reports for the month of September of 2024 and found no account of reported restraints or staff to resident interventions. At this time there is not enough evidence to support the allegation of, “Staff inappropriately restrained resident.” and is unsubstantiated at this time. As to the allegation of, “Staff are not safeguarding resident’s personal belongings.” It was alleged that R1 had lost two sets of R1’s dentures. Additionally, a toothbrush that was dirty and black was found. It was discovered through interviews that on 09/16/2024, LPA Jeffries conducted interview with Facility Administrator, Adam Bramwell, who stated that R1’s Responsible Person (F1) brought to the facilities attention that R1’s dentures were missing. Administrator stated that they instructed staff to conduct a through search in memory care unit for missing dentures, but they were not found. On 01/22/2025 LPA interviewed F1, who stated that they were aware of one set of dentures being missing, they reported to the facility and the facility conducted a search but did not find the dentures. F1 also stated that R1 has had a history of hiding their dentures and sometimes throwing them into the trash and did not dismiss this possibility in this instance. F1 stated that they facility followed through in their responsibility and due diligence to locate the missing dentures. On 09/16/2024, LPA Jeffries interviewed S1, S2, S4, and S5, all had been instructed to search for missing dentures which were not found. Additionally, S1, S2, S4, and S5 were all shown a picture of the dirty black toothbrush, and all stated they had never seen that toothbrush before and would have collected it and notified supervisors if they had seen a toothbrush in that condition. CONTINUED on LIC9099-C On 09/16/2024, LPA Jeffries noted on an inspection of R1’s room one clean toothbrush that appeared to show normal use which was the brand of Oral B, two unused new toothbrushes that were the brand of Colgate, all had R1’s name written on the handle of the toothbrushes, however the dirty black toothbrush, was not a brand name toothbrush nor did it have R1’s name on the handle. At this time there is not enough evidence to substantiate the allegation of, “Staff are not safeguarding resident’s personal belongings.” and is unsubstantiated at this time. As to the allegation of, “Staff are not ensuring resident is showered.” It was alleged that R1 was not getting showers. It was discovered through interviews and documentation that on 09/16/2024, LPA Jeffries interviewed R1, who stated, “Staff take good care of me, I like the staff.” and that their (R1) needs were always met and have never had an issue with care, including bathing and incontinence. On 09/16/2024, LPA Jeffries conducted interviews with S1 and S2 who stated that showers for R1 are offered 4 times per week, and often R1 would refuse showers. S1 and S2 stated that they would let supervisor know and note in the shower refusal log when R1 would refuse shower. S1 and S2 stated that R1 would normally be showered one to two time per week on average. LPA Jeffries reviewed facility documents labeled “Shower Refusal” for R1, which shows that R1 had refused showers on 10 occasions during the time period of August 15 through September 15th of 2024 which is a refusal of 10 of 20 shower days. On 01/22/2025 LPA conducted an interview with F1, who stated that the facility will call F1 who is R1’s responsible party and notify F1 when R1 has a shower refusal. F1 stated the facility will call but not always the same day. At this time there is not enough evidence to substantiate the allegation of, “Staff are not ensuring resident is showered.” and is unsubstantiated at this time. As to the allegation of, “Staff left resident in soiled diapers for extended period of time.” It was alleged that, facility are leaving R1 in soiled diapers for a long time. It was discovered through interviews on 09/16/2024, LPA Jeffries interviewed R1, who stated, “Staff take good care of me, I like the staff.” and that their (R1) needs were met and have never had an issue with care, including bathing and incontinence. On 09/16/2024 LPA Jeffries conducted an interview with S1, S2, S4, and S5, who all stated that residents are monitored throughout the day for incontinence and incontinence is always addressed when needed. On 01/22/2025, LPA Jeffries conducted an interview with F1 who stated, the facility dose a good job with R1’s incontinence and had never had an issue or problem with the facility addressing R1’s incontinence in a timely manner. At this time there is not enough evidence to support the allegation of, “Staff left resident in soiled diapers for extended period of time.” and is unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Jan 23, 2025 · control 29-AS-20240912163515

Type of visit: Required - 1 Year

At 9:00am on 01/23/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the facilities annual inspection. LPA met with facility Administrator, Adam Bramwell, announced who he is and the reason for the visit. Additionally, LPA will issue final findings to a separate complaint on a separate report on this date. At 12:30pm, Administrator and LPA conducted a full facility walk through and tour. LPA noted that the facility has a 130 person capacity and has a current census of 96. The facility exterior has walking path around the entirety of the facility and a covered main entrance. There is a designated smoking area just out side the dining-room entrance that has a covered gazebo on the side of the facility. LPA noted that the memory care unit of 15 resident room with on suite bathrooms located in the back of the facility and has a fenced outdoor area that is also in the back of the facility, which has tables and umbrellas for shade. LPA noted that the facility has a outdoor courtyard in the middle of the facility which also has tables and umbrellas for shade. LPA did not observe any issues or violations on the outside areas of the facility. LAP noted that this facility is two stories and has 4 distinct wings. On the first floor there area 35 resident rooms with on suite bathrooms, On the second floor there are 50 resident rooms with on suite bathrooms. LPA inspected a sample of rooms rooms and noted that all rooms had working lights, ample storage, working appliances and non-skid surfaces in the showers. LPA observed that there is a medication room, physical therapy room, laundry room, snack bar area with seating, beauty shop, and an tv activity room on the second floor. LPA noted that all three stair wells had emergency fire chair at the top of the stairwells. LPA noted that the dining room, kitchen, laundry room, staff room, maintenance room and employee entrance on the first floor on the north side of the building. LPA noted that the front entrance has offices and reception desk, and a lounging room for residents. LPA note that there are assorted offices on both the first floor and second floor. LPA noted that there were fire extinguishers placed all throughout the facility, all fire extinguishers that were inspected were in the prime and charged in the green. LPA observed working carbon monoxide detectors through out the facility. CONTINUED on LIC809-C LPA noted that all walkways and entrances were free and clear of debit. At 9:40am Administrator and LPA conducted a full review of the facility annuals control tools module. LPA noted that no citations or violations as result of the annual care tool modules review. LPA noted that the annual facility inspection resulted in no violations or citations at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Jan 23, 2025

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility failed to notify responsible party/physician in residents change of condition. Facility did not provided change of contract notification. Facility did not observed residents change of condition. Facility did not follow terms of admission agreement. Facility staff are not properly trained.

At 8:45am on 12/19/2024, Licensing Program Anaylist (LPA) Jeffries arrived to the facility unannounced to issue final finding to the allegations to this complaint. LPA met with Administrator Adam Bramwell, annoucned who he is and the reason for the visit. As to the allegations of, “Facility failed to notify responsible party/physician in residents change of condition.”, “Facility did not observed residents change of condition.”, “Facility did not follow terms of admission agreement.”, and “Facility did not provided change of contract notification.” It was alleged that there was a lack of communication, and not replying to calls or emails to the family or physician’s a notification in R1’s change of condition. It was discovered through documentation and interviews of the following: On 05/15/2024, LPA Jeffries reviewed R1’s Admissions Agreement dated 02/15/2024, this Admissions Agreement was initialed and singed in all applicable notations with the following notable acknowledgements: CONTUNED on LIC9099-C Unsubstantiated R1 identified and initialed that this agreement was with the facility corporation, R1 and “self” indicating that R1 was independent of a designated representative by the contract. It is noted that there was a clause in the contract that in the event of Death, F1 was designated as the person to remove R1’s property. There were no other items in the contract as to a representative or designated person of R1 in this Admission Agreement. Additionally, on 05/15/2024, LPA reviewed R1’s Physicians Report (LIC602) dated 02/13/2024, two days prior to R1’s move in date to the facility, which did not notate any cognitive decline, and noted that R1 could leave the facility unassisted. On 05/15/2024, LPA reviewed, R1’s Central Coast Home Health Care, Admission Service Agreement, singed and dated on 02/18/2024 which indicated and marked as “I DO NOT have a durable Power of Attorney for Health Care.” Which was singed by R1 on 02/18/2024. On 05/06/2024 and 05/15/2024, LPA Jeffries reviewed 9 pages of transcripts submitted by F1 indicating outlining, weekly to daily communications with Administrator, Adam Bramwell, Facility Wellness Director (S1) pertaining to R1’s medical appointments, medication changes and concerns, billing explanations, insurance benefits, and general condition of R1. On 05/06/2024, LPA interviewed F1, who stated that they have been in communication with Administrator Adam Bramwell, and S1 through email, text, and phone calls multiple time a week during R1’s stay at the facility. On 05/10/2024 LPA Jeffries interviewed Administrator, Adam Bramwell who stated that they had continuous contact with F1 through phone (mostly in the evenings due to global location of F1), text, and emails. On 05/10/2024 LPA Jeffries interviewed S2 who stated that they have had continuous contact with F1 through emails during F1’s stay at the facility. LPA noted Based on documentation, and interviews, there in not enough evidence to support the allegations of, “Facility failed to notify responsible party/physician in residents change of condition.”, “Facility did not observed residents change of condition.”, “Facility did not follow terms of admission agreement.”, and “Facility did not provided change of contract notification.” and are all unsubstantiated at this time. CONTINUED on LIC9099-C At to the allegation of, “Staff are not properly trained.” It was alleged that on February 17th Staff 3 (S3) and Staff 4 (S4) did not know how to change the portable oxygen bottle for R1. It was discovered through interviews and documentation that on 05/06/2024, LPA conducted a phone interview with W1. W1 stated that R1’s portable oxygen tank was delivered “either the 16th or the 17th of February. 12/18/2024 LPA Jeffries conducted phone interviews with S4 who stated that Facility Health Care Director provided in “impromptu” training to all care staff that were working 02/19/2024 a training on the specific functions of R1’s portable oxygen tank. S1 stated that they have over a year experience as Medication Technician and Care Giver and has had experience and prior training with Oxygen for residents. LPA noted that the arrival of the new equipment (R1’s portable oxygen tank) on a weekend did not allow reasonable time for staff training. LPA noted that the “impromptu training took place on 12/18/2024 at the first available date for training by a qualified trainer. LPA reviewed all staff training records that were working at the facility on 12/17/2024 which included S3, S4, S5, S6, S7, and S7. S3-S7 all had met or exceeded the annual number of hours of training per regulations. LPA noted that the facility exercised due diligence in the training of the new equipment (R1’s portable oxygen) on the first available date. At this time there is not enough evidence to support the allegation of, “Staff are not properly trained,” and is unsubstantiated at this time. Exit interview, report read, and report provided. On 02/19/2024 R1 had a follow up doctor’s appointment where new medication orders for R1 which changed the Furosemide 40mg to 1 tab PO qDay (Once per day) under the supervision of Phys2. On 03/05/2024, at the request of the W1, facility submitted a request to Phys3 for R1 to have Furosemide 40mg BID. On 03/07/2024 a return fax order which stated, “R1 can increase Furosemide 40mg BID for 5-7 days until swelling improves…” The final order that the facility received was for Furosemide 40mg BID was received on 03/28/2024 from Phys3. Upon admission to the facility on 02/16/2024, R1’s Medication Administration Record (MAR) from the facility shows R1 to have Furosemide 40mg administered twice per day (8am and 12pm) on date February 16, 17, 18, and 19, as prescribed by Phys1, which are the correct dosage time per Physicians orders as referenced above. Orders dated 02/19/2024 by Phys2, prescribing Furosemide 40mg qDay (once per day) as noted above where not followed according to Physician orders. As evidence by the facilities MAR, which shows that R1 continued to received Furosemide 40mg BID, from the dates of February 19, 20, 21, 22, 23, 24, 25, 26, 27, 28. On February 29th facility MAR shows Furosemide 40mg administered at 8am and Discontinued (DC) for the 12:00 pm time, however the facility did not present any physicians orders for this DC notation on February 29th. The facility March of 2024 MAR notes that the correct time and dosage of Furosemide 40mg as per Physicians orders were followed from March 7-12 was followed a per Physician Orders, as evidence of the facility MAR and the faxed order from Phys3 on 03/07/2024. Facility March MAR also noted that no Furosemide 40mg was administered between the dates of March 15, 16, 17, 18, 19, 20, and 21 as per Physicians order. LPA Jeffries reviewed facility documents titled Incident Notification dated 04/17/2024, indicating that R1 was transported to the hospital for shortness of breath, however this was not reported and documents requested were not provided to determine how long R1 was in the hospital based on that facility incident report. Which puts the facility March 2024 MAR for the dates of March 15-21 in question as there is no note of Furosemide 40mg in question of multiple doctors’ orders which do not specify to DC or continue once per day. Facility MAR for March and April show that Furosemide 40mg was administered per Physicians order based on last prescription from Phys3 of Furosemide 40mg BID. Based on MAR, Physicians Orders, and CSMR, there is enough evidence to show that during the time period of February 19-28, R1 was not administered medication by the facility as prescribed by a physician. Therefore, the allegation of, ““Facility failed to provide resident with correct medication dosage.” Is substantiated at this time. Exit interview, report read, citation issued, appeal rights and report provided.the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 29-AS-20240506140046

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5)(A) · Plan of correction due date: Dec 20, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical … provide for assistance in obtaining such care, by compliance with the following: (5) … Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician. This requirement was not met by evidence of MARs indicating medication not provided in accordance to Physicians order in February of 2024. Which poses an imminent risk to Residents in care.the state’s words, verbatim · CDSS document, Dec 19, 2024

Plan of correction: Administrator agrees to conduct two hours of Medication training that includes medication initial intake, documentation, and medication distribution. Administrator will review and revise Medication Administration policy with all employees and proved LPA a copy of all staff 2 hour Medication training, as well as the facility’s current and updated medication distribution policy to LPA by 12/20/2024.

Allegation investigated: Resident sexually abused while in care. Resident sustained unexplained bruising while in care. Staff do not ensure that resident takes medication as prescribed. Staff do not ensure resident's incontinence needs are meet. Staff do not assist residents with showering. Staff do not provide resident with housekeeping service. Staff do not ensure that resident's dietary needs are met. Staff engaging in food preparation are not observing sanitation practices. Staff do not ensure that the facility is maintained sanitary.

At 9:30am on 08/29/2024, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to deliver the final findings to all the allegation to this complaint. LPA met with facility Administrator Adam Bramwell, announed who he is and the reason for the visit. As to the allegation of, “Resident sexually abused while in care.” It was alleged that Reporting Party (RP) was told by Staff that Resident 1 (R1), had stated “He raped me”. It was discovered through interviews, observation and documentation that on 11/02/2023, LPA Jeffries attempted to conduct an interview with Resident 1 (R1). R1 was cognitively unable to answer questions of LPA when asking basic screening questions (ie: what is your name? Do you know where you are right now?), R1 did not answer. LPA noted that approximately 15 minutes after the attempted interview, R1 was yelling several profanities at staff. On 11/02/2023, LPA interviewed Wellness Director (S1). S1 stated that the facility has been aware of R1’s statements of alleged sexual abuse and facility investigated pertaining to R1’s statements; CONTINUED on LIC9099-C Unsubstantiated S1 stated that R1 denied any sexual acts that have happened while in the facility, additionally, there are no male staff currently or recently assigned to the memory care unit where R1 resides. S1 stated that staff that work with R1 were instructed to monitor who enters or exits R1’s room, staff have not observed any male enter R1’s room. S1 stated that R1 exhibits overt sexual language when R1 is upset which has been a consist behavior from the beginning of R1’s residing at this facility, according to S1 interview on 11/02/2024. On 11/02/2023, LPA interviewed Staff 3-10, (S3-S10), all stated that R1 typically exhibits explicit profanity as a normal behavior for R1 and has refused care giving assistance when upset.. On 11/02/2024, LPA, S1 and facility Administrator conducted an interview with S2. S2 stated that they had a conversation with a staff member about R1 but did not provide any other details about R1 other then what R1 stated, “He raped me”. Based on interviews, observations and documentation, at this time there is not enough evidence to support the allegation of, “Resident sexually abused while in care.” and is unsubstantiated at this time. As to the allegation of, “Resident sustained unexplained bruising while in care.” It was alleged that Resident had bruises all over their body and look like finger bruises. It was discovered through interviews, observations, and documentation that, on 11/02/2024, LPA Jeffries attempted to interview R1, and R1 was not responsive to basic screening questions. LPA did observe one red bruise on the left forearm of R1 that was approximately 2” with round shape and no indication in the shape that could determine how the bruise may have occurred. On 11/02/2023 LPA Jeffries reviewed R1’s LIC602 (Physicians Report) that indicated a primary diagnosis of Edema. On 11/02/2023, LPA interviewed Staff 3-10, (S3-S10), all stated that R1 typically exhibits explicit profanity as a normal behavior for R1 and has refused care giving assistance when upset. S3-10 stated they have not observed any other bruising on R1’s body other than the left forearm bruise. Based on interviews, observations, and documentation there is not enough evidence to support the allegation of, “Resident sustained unexplained bruising while in care.” and is unsubstantiated at this time. As to the allegation of, “Staff do not ensure that residents take medication as prescribed.” and, “Staff do not ensure residents’ incontinence needs are met.” It was alleged that staff do not properly administer medication to R2 and R2 “stashed” medication in their drawer as well as R2 left in soiled briefs for extended periods. On 11/02/2023 LPA Jeffries conducted an interview with R2, R2 stated that they have always take medication when provided by staff. R2 denied hiding or stashing medications at any time. R2 stated that staff do a good job with incontinence needs and medications including prescribed ointments as need. LPA observation during interview, noted that no medications or ointments were in R2’s drawers. On 11/02/2024 LPA Jeffries reviewed R2’s LIC602 (Physicians Report) which indicated UTI as a secondary diagnosis. CONTINUED on LIC9099-C LPA also observed Centrally Stored Medication Record (CSMR) and Medication Administration Record (MAR)for R2 and did not find any missed medications. LPA reviewed Physician notes on facility visit of R2 on 08/22/2023 and 09/05/2023 both listing frequent UTI’s. On 11/03/2023, LPA reviewed facility serious incident reports (SIR) and did not find any SIR’s with R2 as the subject. LPA interviewed S3-10, who all stated that medications are always given as prescribed to their knowledge. S3-S10 all stated that all residents are always monitored for incontinence and cared for when incontinence care is needed. Based on interviews, observation, and documentation, there is not enough evidence to support the allegation of, “Staff do not ensure that residents take medication as prescribed.” and “Staff do not ensure residents’ incontinence needs are met.” are both unsubstantiated at this time. As to the allegation of, “Staff do not assist residents with showering.” It was alleged that R2 and R3 were not regularly showered. It was discovered through documentation and interviews that on 11/02/2023 LPA Jeffries reviewed Admissions agreements, Level of Care Plans, Shower Schedules/Refusal documents for R2 and R3. Both R2 and R3 were assessed at the highest level of care (facility Level 6) provided by the facility. On 11/02/2023, LPA interviewed R2, who stated that the staff take care of bathing needs daily, most often while in bed. R2 stated that staff did a good job of keeping R2 clean. On 11/02/2023, LPA Jeffries conducted and interview with R3 who stated that the facility helps with shower daily. LPA observed and noted during the interview that R3’s room was clean and did not have any apparent emanating orders. LPA noted that R3’s facility care plan outlines daily shower as confirmed by R3. On 11/02/2023, LPA Jeffries conducted interviews of S3-S10 who all stated, stated that all residents are monitored at all times for incontinence and cared for when incontinence care is needed. Based on interviews, documentation, and observations, at this time there is not enough evidence to support the allegation of, “Staff do not assist residents with showering”. and is unsubstantiated at this time. As to the allegation of, “Staff do not ensure that residents’ dietary needs are met.” It was alleged that staff “throw” food in front of R2, then leave. It was discovered through documentation and interviews that on 11/02/2023, LPA Jeffries interviewed R2. R2 stated that they have never had any issues with food service at this facility. R2 denied that staff threw or left food for R2 at any time. On 11/02/2023, LPA conducted interviews with S3-S10, all staff were aware that R2 required meals to be set up for R2. All denied throwing or leaving food for R2 that R2 was not able to consume. On 11/02/2023 LPA reviewed R2’s LIC602 (Physicians Report) which indicated that R2 is able to feed self, with “set up assistance.” At this time there is not enough evidence to support the allegation of, “Staff do not ensure that residents’ dietary needs are met.” And is unsubstantiated at this time. CONTINUED on LIC9099-C As to the allegations of, “Staff do not provide residents with a housekeeping service.”, “Staff do not ensure that the facility is maintained sanitary.”; and “Staff engaging in food preparation are not observing sanitation practices.” It was alleged that; Kitchen staff do not wash hands when preparing meals for residents. And dining mats are not sanitary. And R3’s room smells of urine and is not cleaned. It was discovered through interviews, photographs, documentation, and observations that, on 11/02/2024 LPA Jeffries conducted an interview with R3. R3 stated that the facility helps with shower daily. LPA observed and noted during the interview that R3’s room was clean and did not have any apparent emanating orders. On 11/02/2023, LPA Jeffries interviewed S3-S10 who all confirmed R3 had incontinence behaviors that are continuously being addressed by staff and housekeeping staff. S3-S10 all confirmed that housekeeping staff will address any cleaning problems as needed on top of their normally schedule cleaning tasks. On 11/02/2023 LPA reviewed facility housekeeping schedule and noted no gaps or call offs in house keeping schedule. On 11/02/2023 LPA Jeffries observed kitchen staff preparing lunch, all were wearing black gloves. LPA interviewed Kitchen Staff S13 who stated that all food preparation is conducted with gloves for hygiene and sanitary reasons. LPA observed and photographed dining place mats and noted all were clean and free of stain and foods. On 04/09/2024, at approximately 10:50am, Administrator Adam Bramwell and LPA Jeffries conducted a visual inspection of all 14 bathrooms in the memory care unit. LPA photographed and noted that 13 of 14 bathrooms were clean and in good working order. LPA noted that the one bathroom in question was cleaned, however the floor was sticky. This was discovered to not be a sanitation issue but a floor material issue that is being addressed by the administrator. On 04/09/2024, LPA Jeffries interviewed Memory Care Staff 5, 11, and 12 (S5, S11, and S12), who all stated that their job duties included cleaning restrooms as needed. S5, S11 and S12 all stated that they knew they could call housekeeping on the radio if there was a need to have a residents restroom cleaned due to an immediate need. LPA noted that there was no evidence on this visit to indicated that staff do not ensure resident’s restrooms are cleaned and sanitized. LPA reviewed documentation (Job Description) of staff duties of Pegasus Senior Living for the position of Care Partner that included but not limited to, “Maintains clean, neat, comfortable, safe environment for Residents, Staff and visitors, including housekeeping services for Residents.” Which S5, S11, and S12 all acknowledged in interviews on 04/09/2024. At this time, there is not enough evidence to substantiate the allegations of, “Staff do not provide residents with a housekeeping service.” “Staff engaging in food preparation are not observing sanitation practices.” and “Staff do not ensure that the facility is maintained sanitary.” and all are unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 29-AS-20231101084515

Allegation investigated: Staff do not ensure resident's restrooms are clean and sanitized.

At 9:45am on 04/09/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the initial investigation to the allegation to this complaint. LPA met with Administrator, Adam Bramwell, announced who he is and the reason for the visit. LPA conducted a facility tour, took photographs, made observations, collected and reviewed documents and conducted interviews. LPA issued final findings below: As to the allegation of, “Staff do not ensure resident's restrooms are clean and sanitized.” It was alleged that approximately 04/03/2024, Residents in Memory Care Units bathrooms were unsanitary and unclean. On 04/09/2024, at approximately 10:50am, Administrator Adam Bramwell and LPA Jeffries conducted a visual inspection of all 14 bathrooms in the memory care unit. LPA photographed and noted that 13 of 14 bathrooms were clean and in good working order. LPA noted that the one bathroom in question was cleaned, however the floor was sticky. This was discovered to not be a sanitation issue but a floor material issue that is being addressed by the administrator. CONTINUED on LIC9099-C Unsubstantiated On 04/09/2024, LPA Jeffries interviewed Memory Care Staff 1, 2, and 3 (S1, S2, and S3). S1-3 all stated that their job duties included cleaning restrooms as needed. S1-3 all stated that they knew they could call housekeeping on the radio if there was a need to have a residents restroom cleaned due to an immediate need. LPA noted that there was no evidence on this visit to indicated that staff do not ensure resident’s restrooms are cleaned and sanitized. LPA reviewed documentation (Job Description) of staff duties of Pegasus Senior Living for the position of Care Partner that included but not limited to, “Maintains clean, neat, comfortable, safe environment for Residents, Staff and visitors, including housekeeping services for Residents.” Which S1-3 all acknowledged in interviews on 04/09/2024. At this time, there is not enough evidence to substantiate the allegation of, “Staff do not ensure resident’s restrooms are clean and sanitized.” And is unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Apr 9, 2024 · control 29-AS-20240404095309

Allegation investigated: Facility staff billed resident for services not rendered. Facility staff mismanaged resident medication.

At 9:45am on 04/09/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to issue final findings to the allegations to this complaint. LPA met with Administrator, Adam Bramwell, announced who he is and the reason for the visit. As to the allegations of, “Facility staff billed resident for services not rendered.” It was alleged that R1 was billed for services not rendered during the months of July through August 2023. It was discovered through interviews on 10/26/2023, LPA Jeffries conducted a phone interview of Family Member 1 (F1) that Resident 1 (R1) had been billed for the month of June for two different levels of care (Level 1 and level 2), also had not been provided access to at least 2 staff assisted showers per week after 06/01/2023, and a refund due of medication that was discontinued by R1’s Physician, that had been recorded after the Physicians discontinued order. On 10/26/2023, LPA Jeffries interviewed facility staff 2 (S2) who presented documentation of billing statement from 07/01/2023 through Octobers final billing statement. S2 explained that a higher level of care was assessed for R1 by S1 on 06/01/2023, CONTINUED on LIC9099-C Unsubstantiated additionally there was a Care Conference Acknowledgement meeting on 06/01/2023 with S1, R1, and over the phone, F1, to address the change in level of care and charges associated with the higher level of care. Due to the billing cycle of the facility uses for charging residents, both levels 1 and 2 of care were billed in the month of June 2023 without being pro-rated. The refund for the prorated amount for the change in care in question was reimbursed to R1/F1 on the Octobers billing statement. Interviews with Staff 3-6 (S3, S4, S5 and S6), indicated that R1 had verbally denied shower assistance on more than one occasion. There is no written record of shower refusal, however, all three care staff who were tasked to shower R1 stated similar denial of showers by R1. With respect to the medication refund, there was a medication order from the R1’s physician to “put a hold” on the medication in question on 06/06/2023. That medication was then discontinued by the physician on 06/23/2023 by fax from R1’s physician. The medication discontinue order by R1’s Physician was sent to Omni Care (the company handling the pharmacy order) on the same day 06/23/2023. Omni care sent the medication despite the discontinued order. In an interview with S1, S1 stated that Omni Care refused to rerun the missed ordered medication. S1 stated that they informed F1 that they would pay for that month’s medication if Omni Care refused to reimburse R1/F1. On 02/12/2023 LPA interviewed F1 by phone a second time. F1 stated that they did receive a prorated bill amount in October 2023 for June 2023 double billing of levels of care. F1 stated that they were unaware of R1’s refusals of showers. F1 stated that they did not follow up on the medication refund because of the passing of R1 and the minimal amount of the medication charge. Based on interviews, documentation, and admissions, there is not enough evidence to support the allegation of, “Facility staff billed resident for services not rendered.” and is unsubstantiated at this time. CONTINUED on LIC9099-C As to the allegation of, “Facility staff mismanaged resident medication.” It was alleged that the facility ordered medication for R1 that had been discontinued. On 10/26/2023, LPA Jeffries reviewed documentation provided by the facility of R1’s physician order on a prescription dated 06/06/2023. The prescription order read “hold medication” meaning, do not administer the medication, starting 06/06/2023. LPA reviewed a fax from R1’s new physician on 06/23/2023 ordering the DC (discontinue) of the specific medication for R1. LPA interviewed S1 on 10/26/2023, where S1 stated that they faxed the DC order to Omni Care (the company handling the pharmacy order). Due to the timing of the order (3 working days) the medication was filled by Omni Care. S1’s stated that they attempted to return the DC ’ed medication to Omni Care, however Omni Care refused. S1 stated as a gesture of good faith, S1 offered to reimburse F1 (R1) the cost of the medication, if they also had attempted to get a refund due to Omni Cares oversight on the Physicians DC order of 06/23/2023. S1 stated that they never heard back from F1 about the medication refund from F1 contacting Omni Care. LPA observed the facilities medication destruction order for this medication in question for the remainder of the June prescription 06/07/2023- 06/30/2023, and the medication destruction order for the July order. LPA noted that the facility acted in due diligence with regards to handling of the medication in question. On 02/12/2023 LPA interviewed F1 by phone a second time. F1 stated that they did not follow up on the medication refund because of the passing of R1 and the minimal amount of the medication charge. At this time there is not enough evidence to support the allegation of, “Facility staff mismanaged resident medication.” and in unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Apr 9, 2024 · control 29-AS-20231023105727

Allegation investigated: Staff do not respond to call bell in a timely manner. Facility does not provide adequate food service.

At 9:57am on 02/15/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to issue final finding to this complaint and in a separate report conduct the annual facility inspection. LPA met with Interim Administrator, Adam Bramwell announced who he is and the reason for the visit. As to the allegation of, “Staff do not respond to call bell in a timely manner.” It was discovered through documentation and interviews that R1’s call bell record from this facility indicated that between the days of April 8th, 2023, through June 8th, 2023, R1’s call pendent was pressed 87 times, during that time there were a total of 5963 total calls at the facility from an average of 60 residents who have call pendants. R1’s 87 calls represent less than .02% of total calls during that time period. Of those 87 calls, 42 calls (48% of R1’s calls) took longer than 10 minutes for facility staff to respond. This included the following call time responses: one call response time of over 50 minutes, one of over 40 minutes, four of over 30 minutes, eleven of over 20 minutes, twelve over 15 minutes, and thirteen calls of over 10 minutes that it took facility staff to respond to R1’s call pendant once it was pressed by R1. CONTINUED on LIC9099-C Substantiated Interviews of Staff 1 – 4 (S1, S2, S3, and S4) on 06/08/2023, all stated that there is not enough staff to fully attend to all resident needs. Based on call times, interviews, and documentation there is sufficient evidence to conclude that the facility, during the time of this investigation, did not have staff sufficient in numbers to provide services necessary to meet resident’s needs and the allegation of, “Staff do not respond to call bell in a timely manner.” Is substantiated at this time. As to the allegation of, “Facility does not provide adequate food service.” It was discovered through interviews, documentation, and observations that food service at the facility on three specific weekends of May 20/21, May 27/28, and June 03/04, dining services were delivered cold and below basic standards meal offerings. In interviews on 06/08/2023, of staff 3-6 (S3, S4, S5, S6, and S7) all stated that lead staff (S2) working weekends was not properly trained and did not have enough head cook experience to manage basic food service during these dates. In interviews of Residents on 06/08/2023 R2, R4, R5, and R6 stated that the food service has been cold on the weekends during the May through June of 2023 time period. Based on interviews of Staff and Residents, at this time there is enough evidence to support the allegation of, ““Facility does not provide adequate food service.” and is substantiated at this time. Exit interview, report read, deficiency cited, appeal rights and report provided.the state’s words, verbatim · CDSS document, Feb 15, 2024 · control 29-AS-20230601115306

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Feb 29, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. … This requirement was not met by the number of call response times with R1 that exceeded 10 minutes which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Feb 15, 2024

Plan of correction: During time of complaint investigation facility employed contract staff due to low staffing. Current staffing meet or exceed standards to meet current resident census needs.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(9) · Plan of correction due date: Feb 29, 2024

87555 General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met by evidence of Resident and Staff interviews verifying cold meals were served on serval occasions, which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Feb 15, 2024

Plan of correction: During the time of this complaint facility employed staff that did not have adequate training. At the time this LIC9099-D was singed kitchen staff have proper training and POC is met.

Type of visit: Required - 1 Year

At 9:57am on 02/15/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA met with Interim Administrator, Adam Bramwell announced who he is and the reason for the visit. Administrator and LPA conducted a full facility walk through and tour. LPA noted that the facility has a 130 person capacity and has a current census of 74. The facility exterior has walking path around the entirety of the facility and a covered main entrance. There is a designated smoking area just out side the dining-room entrance that has a covered gazebo on the side of the facility. LPA noted that the memory care unit of 15 resident room with on suite bathrooms located in the back of the facility and has a fenced outdoor area that is also in the back of the facility, which has tables and umbrellas for shade. LPA noted that the facility has a outdoor courtyard in the middle of the facility which also has tables and umbrellas for shade. LPA did not observe any issues or violations on the outside areas of the facility. LAP noted that this facility is two stories, it has 4 wings. On the first floor there area 35 resident rooms with on suite bathrooms, On the second floor there are 50 resident rooms with on suite bathrooms. LPA entered a sample of rooms (10) rooms and noted that all rooms had working lights, ample storage, working appliances and non-skid mats in the showers. LPA observed that there is a medication room, physical therapy room, laundry room, snack bar area with seating, beauty shop, and an tv activity room on the second floor. LPA noted that all three stair wells had emergency fire chair at the top of the stairwells. LPA noted that the dining room, kitchen, laundry room, staff room, maintenance room and employee entrance on the first floor on the north side of the building. LPA noted that the front entrance has offices and reception desk, and a lounging room for residents. LPA note that there are assorted offices on both the first floor and second floor. LPA noted that there were fire extinguishers placed all throughout the facility, all prime and charged in the green. LPA observed working carbon monoxide detectors through out the facilty. LPA noted that all walkways and entrances were free and clear of debit. Administrator and LPA conducted a full tool module review and no violations of or citations were noted. One Technical Violation was issued on late Administrator Certificate which will be corrected on May 22, 2024. Exit interview, report read, no violations, and report provided.the state’s words, verbatim · CDSS document, Feb 15, 2024

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.