Ingleside Assisted Living

Allegation investigated: Due to lack of staff intervention, an altercation between residents resulted in injuries.

On 6/8/23 at 11:01 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced subsequent complaint visit to the deliver findings for the above allegation. LPA met with Brett Allan, Licensee, and Nikole Daugherty, Administrator, and explained the reason for the visit. On 03/02/2023, the Department received a complaint alleging “Due to lack of staff intervention, an altercation between residents resulted in injuries.” It was alleged that facility Staff #1 (S1) failed to intervene when Resident #1 (R1) and Resident #2 (R2) had a physical altercation which resulted in R1 sustaining injuries. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Elisia Rippe. Continued on 9099-C. Substantiated On 03/02/2023, from 1:00pm to 2:15pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced 24-hour initial complaint visit. LPA met with Brett Allan, Licensee, and Nikole Daugherty, Administrator, and explained the purpose of the visit. The LPA interviewed the Licensee and Administrator and obtained copies of documents and surveillance video pertinent to the investigation. Investigator Rippe conducted the following interviews: On 03/30/2023, at 1:29pm, with Administrator; on 04/24/2023, from 10:57am to 11:32am, with R1, Resident #3 (R3), Resident #4, and Administrator; on 05/15/2023, at 11:11am, with S1; on 05/16/2023, at 11:59am, with Administrator; and on 05/17/2023 with R1’s resident representative. In addition, Investigator Rippe reviewed Atascadero Police Department (APD) report #23-0431, San Luis Ambulance report, Twin Cities Community Hospital medical records and facility file documents related to R1 and R2, including the surveillance video of the 02/21/2023 incident and photos of R1’s injuries. According to the APD report, police responded to the facility on 02/21/2023 at approximately 11:13pm. S1 stated to police that R2 hit R1 with a closed fist and R1 fell and hit their head. S1 stated R2 was standing next to R1 and R1 began scratching R2’s arms. S1 stated R2 hit R1 one time with a closed fist on the left side of forehead and R1 fell to the ground. S1 stated R1 got back on their feet and began scratching R2’s arms again. S1 stated R2 struck R1 in the face again with a closed fist, hitting R1’s left cheek bone. R1 lost balance and fell to the ground again. The officers attempted to speak with R1 but R1 was unable to articulate what happened. The report stated R1 has Dementia. The officers spoke with R2 who stated they were unsure if the altercation was with a female or male. R2 said they potentially kicked R1 in the head after R1 attacked R2 by grabbing R2. R2 was unable to articulate any further details of the incident. R1 was transported to Twin Cities Community Hospital and received stitches to forehead and cheek. Twin Cities Hospital medical records review revealed that R1 was admitted to the hospital on 02/22/2023. The records documented R1 was in an altercation at the facility and R1 suffers from significant dementia. R1 had bleeding from their face and there was no known loss of consciousness. R1 had significant swelling to their left forehead and swelling to the left side of face. There was some dried blood noted to face and some ecchymosis to the palmar aspect of right hand. The CT scan of R1’s head and brain showed no signs of any skull fracture or intracranial bleed. R1 received stitches to close the wounds and was discharged back to the facility. Continued on 9099-C. Facility records reviewed revealed that R1 had a diagnosis of dementia, with conditions of confused/disoriented and inappropriate/aggressive/sundowning behaviors. Facility notes revealed R1 had daily agitation and R1’s doctor, stated R1’s agitation was due to R1’s Alzheimer’s. R1’s agitation started to increase in February 2023 and R1 was prescribed Celexa due to the increase in agitation. The facility updated R1’s resident representative regarding the increase in agitation. R2’s primary diagnosis was listed as Alzheimer’s dementia, with conditions of confused/disoriented, and inappropriate/wandering/sundowning behaviors. There was no aggressive behavior documented in R2’s physician report or needs and services plan. R2 had no prior incidents of attempting to physically assault another resident. Investigator Rippe reviewed the surveillance video of the 02/21/2023 incident. The video shows R2 standing on the outside of the desk counter next to R1. R3 was across the counter from R1 and R2 and R4 was sitting in a chair. S1 was behind the counter. The video shows R1 agitated and trying to grab the copy machine and reaching for S1’s arm. (S1 could not recall what R1 was frustrated about or saying. S1 stated R1 had been agitated from the start of the shift and the evening shift caregiver also stated to S1 that R1 had been agitated throughout their shift). The video shows R1 holding onto a chair and R2 talking to R1. The video shows R2 hit R1 and R1 falling to the ground. The video then shows R1 on the floor scooting towards R2. The video shows R2 sitting in a chair and using their left foot to kick R1 on their face and they fell back. S1 then came from behind the desk to get R1 off the floor and sit in a chair. S1 sat R1 face to face with R2 and then went back behind the desk. R1 got up from chair and reached for S1 (S1 stated they told R1 to stop grabbing S1 and told R1 to sit down as they were on the phone with the police at that time). The video then shows S1 leave the desk area (S1 stated they went to the front door to open the gate to allow APD to come in). The video shows S1 putting gloves on so they could look at R1’s injuries on face (S1 stated R1 would not let S1, APD or the paramedics clean their face). The video shows S1 behind a desk and not assisting R1 for over three minutes during the incident. Per the Administrator, S1 could have comforted R1 and deescalated the situation between R1 and R2. The Administrator further stated, S1 should have kept R1 and R2 away from each other until police arrived. S1 was suspended due to the incident and no longer works at the facility. S1 stated the reason they remained behind the desk for over three minutes and didn’t help R1 after they were hit was because they were looking for the phone number for the paramedics that they had written down. S1 stated they did not witness R2 hitting R1 because they had their back turned to them. Continued on 9099-C. Based on information obtained and reviewed during the investigation, the Department determined that the facility staff failed to provide adequate care and supervision to R1 by not intervening when R1 and R2 had a physical altercation, which resulted in R1 sustaining injuries. Therefore, the allegation “Neglect/Lack of Supervision - Due to lack of staff intervention, an altercation between residents resulted in injuries” is deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted, civil penalty issued, and the report and appeal rights given.the state’s words, verbatim · CDSS document, Jun 8, 2023 · control 29-AS-20230302100956

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Jun 9, 2023

1569.312(a) Basic services requirements. Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff failed to intervene when R1 and R2 had an altercation which resulted in R1 sustaining injuries, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 8, 2023

Plan of correction: Licensee will submit a plan on how you will ensure appropriate care and supervision to residents. Submit to CCL by due date on 6/9/23.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Chavez made an unannounced Annual/Required visit to the facility above. LPA met with Nikole Daugherty, Administrator, and Cathyann Paape, Business Manager, and explained the purpose of the visit. LPA requested a staff roster, a resident roster, emergency and disaster plan, and documentation of quarterly emergency drills. Documentation of quarterly emergency drills was not available. Administrator confirms that drills were completed in March/April 2023 and December 2022 and not prior to that. Deficiency cited. LPA toured the facility with the administrator and the following was noted: LPA observed the license posted, licensing reports, personal rights, non-discrimination notice, LTCO poster, CDSS Complaint Poster, Bill of Rights and Right to Residential Council. The facility has 15 bedrooms and 16 bathrooms, a kitchen, dining room, living room, and courtyard in the front of the facility. Medications are kept in a locked room behind the nurses’ station. Physical plant was check for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, and all were in good condition. The facility maintains a comfortable temperature. The facility provides a working telephone for resident use. Smoke and carbon monoxide detectors were tested and operational. Fire extinguishers (7) are located throughout the facility and were last inspected 9/30/22. One extinguisher was not fully charged. Licensee will get the extinguisher inspected and send CCL a photo of extinguisher by 5/19/23. There are no issues with Fire Clearance. LPA observed cleaning supplies and disinfectants in a locked closet. The facility has cameras inside and outside throughout the facility. Living and dining room furniture were also checked for functionality and condition. The living room and dining room are clean, safe and sanitary. Continued on 809-C. Courtyard of the facility has outdoor furniture, with a covered shaded area for residents in the front yard. There are no bodies of water on the premises. There is plenty of outdoor lighting available for the safety of the residents. External gates have latches and working properly. Kitchen was sufficiently stocked with two-day perishable and seven-day non-perishables. The menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. The refrigerator and freezer were in compliance with temperatures. Resident rooms have beds with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, nightstand and enough lighting for each resident. There is enough linen available to change weekly or more, if need. Bathrooms were checked for cleanliness and proper operation. The hot water temperature measured between 110 F and 115 F degrees in resident bathrooms. Residents have a sufficient amount of supplies for personal hygiene. Soap, paper towels and toilet paper are provided by the Licensee. Grab bars are secured in toilet and shower areas. Showers have non-slip bottoms or mats. Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for current Medical Assessments with TB results, Current Appraisal Needs and Service plans, and signed Admission Agreements. Resident records reviewed are in compliance. Planned activities are offered to residents in care. Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations, Health screening with TB results, current First Aid/CPR, and Administrator Certificate. All staff were associated to the facility. TB records were not available in one out of five staff records reviewed. Deficiency cited. First aid certifications were not available in two out of five staff records reviewed. Four out of five staff records reviewed indicate that there is insufficient documentation showing staff met the minimum hours of required annual training. Deficiency cited. Medications are in a centrally stored and locked room behind the nurses’ station, including over-the-counter medicines. Medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the residents’ doctor. Proper medication dispensing instructions are followed. The first aid kit has all proper items and is current. Exit interview conducted, deficiencies cited, and the report and appeal rights given.the state’s words, verbatim · CDSS document, May 12, 2023

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Chavez conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Brett Allan, and administrator Zolton Soo. This is a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. The facility is a one story. At 10:01 am, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for zero (0) non-ambulatory residents; zero (0) ambulatory residents; and, sixteen (16) bedridden residents. The facility has sixteen (16) private resident bedrooms. All resident rooms have direct exits to the outside. The facility has a fire sprinkler system. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is not a staff room as night staff are awake on the NOC shift. All rooms were free of odors. All window screens were clean and maintained in good repair. There is one (1) bathroom in the hallway which is designated as a staff bathroom. All sixteen (16) resident bedrooms have an attached bathroom. The resident bathrooms have showers with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105*F and 120*F. Continued on 809-C. Resident and staff records are stored in a filing cabinet in the office which is currently located in the hallway between resident Rooms #1 and #2. Medications are centrally stored in a locked closet in the nurses’ station. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in a locked closet in the nurses’ station. Kitchen knives are stored in the kitchen. The kitchen has two (2) locked entrance doors and are only accessible with a code which staff only have. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. The one (1) trash can had a tight fitting lid. Kitchen, laundry and house cleaning supplies are stored in the locked kitchen and laundry rooms. Flies were observed in the dining area. Applicant will install a fly-repellant system. No other vermin were observed. The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room and dining area. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is no fireplace in the facility. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included electronic flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit. The facility smoke alarm system is hard wired. There is a pull station at the front entry of the house and at the exits. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There are six (6) fire extinguishers throughout the facility. They are fully charged and do not exceed the expiration date. Continued on 809-C. The laundry area is located in the hall near bedroom #15. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a storage closet in the entry way. Extra incontinence supplies are stored in resident closets. There is a functioning telephone on the premises in the nurses’ station, phone number 805-460-6541. The emergency exiting plans/sketch are posted in all hallways and at the entrance. The emergency telephone numbers are posted in the hallways next to the emergency exit plans. Other required postings are posted at the nurses’ station and the entrance. The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the front of the facility with tables and chairs where residents can sit. The entire property is fenced with a drive-through gate to enter the property. The pedestrian gate is locked at all times. The gate to the driveway is moved automatically. There are no bodies of water on the premises at the present time. There is no garage nor sheds on the property accessible to residents. The following items must be corrected prior to licensure. Applicant will install a fly-repellant system. Submit proof of corrections, along with a copy of this report, to LPA so that your application may be completed. Exit interview conducted and a copy of report emailed to applicant and administrator.the state’s words, verbatim · CDSS document, May 25, 2022