Lassen House Senior Living

Type of visit: Required - 1 Year

06/17/2026 09:40 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Nicole Braswell and explained the purpose of the visit. LPA Knight and the administrator toured the facility together to ensure the health and safety of residents in care. Assisted Living and Memory Care units were inspected. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas, and dining room. Staff and resident files were reviewed. All employees requiring background checks are cleared. Medication is locked in the medication room. Medication was reviewed. Common area was clean and in good repair. All rooms that were inspected had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. All special dietary needs instructions for residents were posted in the kitchen. All required postings are displayed within facility. Fire extinguishers are fully charged and inspected. Johnson Controls inspected the fire sprinkler system and smoke detectors in April 2026. This inspection is completed every three months. There are no pools or bodies of water are on premises. Last disaster drill was conducted in June 2026 which was an earthquake drill. Facility full evacuation drill is scheduled for July 2026. The facility has been conducting fire drills every month for staff on each shift. No deficiencies are being being cited as a result of today’s inspection. An exit interview was conducted and copy of report was provided to administrator Nicole Braswell.the state’s words, verbatim · CDSS document, Jun 17, 2026

Allegation investigated: Facility is not meeting resident's dietary needs resulting in severe weight loss. - SUBSTANTIATED

/14/2026 09:45 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Nicole Braswell. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation conducted interviews and reviewed documents. Continued on LIC9099-C Substantiated Facility is not meeting resident's dietary needs resulting in severe weight loss. – SUBSTANTIATED It was reported Resident 1 (R1) has lost about 40 lbs. in a year. LPA reviewed 5/28/25 diet order from VA: Minced Moist MM5, Ensure Plus QD. Facility care plan states special dietary needs soft to chew minced and moist. Weight history for R1: 12/06/2023 172.6 lbs., 01/05/2026 137.6 lbs. VA Interdisciplinary plan states difficulty chewing. Goals/Outcomes X 90 days: Intake of adequate calories, protein and fluids by following a texture modified diet. Interventions (for patient and/or caregiver): Registered Dietician (RD) to provide assisted living facility (ALF) with dietary information on preparing texturized foods as needed. VA RN interview stated they did not know that R1 did not have a top denture and had they known they would have ordered a pureed diet for R1. All staff that were interviewed stated that R1 has not had a top denture since they moved into the facility. ED stated that R1 had an ill-fitting top denture when they moved into the facility and R1’s responsible party did not want R1 fitted for a new denture. The VA has changed R1’s diet and R1 is always given extra portions because R1 is always very hungry. R1 consistently drinks Ensure, eats extra portions and snacks . Per ED R1 has a soft and easy to chew diet. It was determined that the facility knew that R1 did not have a top denture and did not communicate this to the VA which resulted in R1 not being prescribed the correct modified diet by the VA. R1 has lost a significant amount of weight. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Nicole Braswell. Staff's negligence and lack of supervision resulted in resident falling. – UNSUBSTANTIATED It was reported that Resident 1 (R1) has a history of repeated falls, requires assistance with all transfers and toileting with most falls occurring when R1 attempts to toilet or transfer themselves. LPA reviewed seven incident reports for falls from April 2025 to January 2026. Two resulted in skin tears and first aid was provided. The remaining five falls were reported as non-injurious. R1 fell out of their wheelchair 3 times, was found on the floor next to their bed twice, and was found on bathroom floor twice (once in common area bathroom). LPA reviewed 90-day home care interdisciplinary treatment plan from the VA dated 01/14/2026 which states R1 is non-ambulatory with a high fall risk and requires caregivers to assist with all transfers. Plan states history of falls in association with lack of care giver oversight. VA RN stated R1 has had several falls and now facility staff are checking on R1 every two hours which is required especially during the night. RN states that R1 has had too many falls from their wheelchair so they worked with VA occupational therapy and added a wheelchair alarm. Staff interviews revealed that R1 has had falls but none resulted in any injury that required treatment beyond first aid. All staff stated they had been trained on the correct way to transfer R1. R1 uses a wheelchair alarm. ED stated that R1 has experienced falls and the facility has increased checks on R1 especially during the PM shift and R1 is toileted more frequently to include before and after meals. The VA ordered a wheelchair alarm for R1 and the facility has implemented its use. It was determined that although R1 has a history of non-injury falls those falls have decreased over the past two months after the facility implemented the VA requirement to increase checks for R1 especially in the night, and have added the wheelchair alarm that the VA requires. This allegation is unsubstantiated. Facility does not follow resident's care plan. – UNSUBSTANTIATED It was reported that staff are not implementing the care plan for Resident 1 (R1). LPA reviewed two interdisciplinary care plans for the dates of 05/28/2025 and 01/26/2026 for R1. VA RN stated there is a binder in the facility that contains the interdisciplinary care plans and every time the RN visits they update the binder with the new care plan which includes care plans for the dietician, physical therapist, RN and an emergency care plan. States every time they are at the facility they discuss their observations with facility staff. Staff stated they follow all care plans for R1. ED stated that R1 is on the home-based home care program through the VA and the VA provides these services at the facility. The VA care plan and notes from their visits are placed in a separate binder for the VA. Our staff implement anything the VA wants in the facility care plan. It was determined that the VA provides interdisciplinary care plans and notes to the facility and staff follows those plans. This allegation is unsubstantiated. This agency has investigated the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted and a copy of the report was provided to administrator Nicole Braswell.the state’s words, verbatim · CDSS document, Apr 14, 2026 · control 59-AS-20260128160816

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(e) · Plan of correction due date: Apr 28, 2026

87463 (e) Reappraisals (e) The licensee shall immediately, or as soon as reasonably possible, bring any significant change in condition, as defined in Section 87101, Definitions, to the attention of the appropriate licensed medical professional and if applicable, other specialized care provider. This requirement was not met as evidenced by: Based on interviews and document review the licensee did not inform the VA that R1 did not have a top denture which resulted in R1 not being prescribed the appropriate diet resulting in significant weight loss which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 14, 2026

Plan of correction: Licensee agrees to conduct a reappraisal of R1, licensee will notify the VA in writing that R1 does not have a top denture, licensee agrees to update R1's dietary requirement as ordered by the VA. Licensee agrees to submit all of these documents to LPA as proof of correction.

Allegation investigated: Facility staff did not maintain complete and accurate residents' records. - SUBSTANTIATED

/18/2025 02:45 PM Licensing Program Analysts (LPAs) Rebecca Knight and Marisa Chiarelli made an unannounced visit to the facility and met with Rosanna Larsen-Burrill Business Services Director. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA conducted interviews and reviewed the following documents: staff list with telephone numbers, Physician’s report, Admission Agreement, needs and services plan, MAR and Resident move in record for 2 residents. Continued on LIC9099-C . Substantiated Facility staff did not maintain complete and accurate residents' records. - SUBSTANTIATED It was reported that the facility could not locate a copy of a resident’s power of attorney (POA) and social security card when requested. LPA reviewed: Resident Move in Record for R1 which includes their social security number. Resident Move in Record for R2 does not include their social security number. Administrator stated that POA documents for the residents have not been submitted to the facility. The facility does not have a social security card on file for R1. R1’s pre-admission paperwork does include R1’s social security number but R2’s pre-admission paperwork does not. Per Title 22 regulations POA documents and social security cards are not required to be included in a resident’s file. However, it is a regulatory requirement that each resident shall have their social security number included in their resident file. 1 of 2 resident files reviewed does not include their social security number. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Nicole Braswell. Facility staff mismanaged residents’ medication. - UNSUBSTANTIATED It was reported that staff discarded a residents Norco and Oxycodone without proper authorization. LPA reviewed: Pharmacy medication list for R1 dated 01/06/2025 for which includes oxycodone 5 mg, order date and start date of 12/03/2024. Fax communication from the facility to R1’s doctor dated 02/17/2025 requesting to discontinue the oxycodone 5 mg for R1 at the POA’s request. R1’s physician signed the request to d/c. Medication Destruction Record for R1 dated 02/25/2025 which states that 15 5 mg oxycodone pills had been destructed and signed off by facility LVN and one other staff. There was no physician’s order for Norco on file for R1. Administrator stated when R1 & R2 moved in they brought a bag of medications with them but they did not have a doctor’s order for oxycodone so the facility had to dispose of the medication. It was determined there was no order for Norco on file for R1. The prescription for Oxycodone was discontinued by R1’s physician on 02/17/2025 and the facility destroyed the 15 remaining pills on 02/25/2025 which meets licensing regulation requirements. This allegation is unsubstantiated. This agency has investigated the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED. No deficiency cited. Exit interview conducted and a copy of the report was provided to administrator Nicole Braswell.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 59-AS-20251014164638

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(2) · Plan of correction due date: Dec 2, 2025

87506(b)(2) Resident Records (b) Each resident’s record shall contain at least the following information: (2) Social Security number. This requirement was not met as evidenced by: Based on records review the facility failed to ensure that 1 of 2 resident records contain a social security number.the state’s words, verbatim · CDSS document, Nov 18, 2025

Plan of correction: The licensee agrees to update the resident record with their social security number and will submit a copy of the document to LPA as proof of correction. POC due date 12/02/2025

Allegation investigated: Staff are mismanaging residents’ medication - UNSUBSTANTIATED

/30/2025 09:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to deliver the results of a complaint investigation. LPA met with Rosanna Larsen- Burrill - Business Services Director and explained the purpose of the visit. During the course of the investigation LPA conducted interviews and obtained the following documents: MAR, admission agreement, care plan, LIC602 Physicians report, appraisal / needs & services plan, medical appointment information for one resident. Continued on LIC9099-C Unsubstantiated Staff are mismanaging residents’ medication - UNSUBSTANTIATED It was reported that Resident 1 (R1) received a diagnosis on 08/19/2025 and a medication was prescribed the same day at 4:56 PM. As of 08/20/2025 4:00 PM the medication had not been picked up because the facility stated they needed a physician’s order first. LPA reviewed R1’s care plan which states that R1 independently manages their own medications. R1’s LIC602 Physician’s Report states that R1 can manage their own treatment, medication, and equipment, is able to administer and store their own prescription medications. LPA reviewed a prescription from R1’s physician which was sent to the pharmacy at 04:57 PM on 08/19/2025. LPA reviewed a written prescription from R1’s physician dated 08/20/2025. There is a handwritten note “clarified order 08/21” on both. Executive Director stated that R1 went to appointment late in the day on 8/19/2025 during which their physician prescribed two medications and called in the prescriptions to a local pharmacy and the facility was not notified by the doctor’s office or the pharmacy. On 08/20/2025 the facility called R1’s doctor’s office three times because they had not received any orders from the appointment and did not receive a return call. That day the pharmacy called and stated they were waiting for clarification from R1’s doctor on one medication. Later that day the pharmacy called and informed they had received the required clarification from R1’s doctor on the order but it was past their delivery time and they could not deliver until the following afternoon. One of the facility directors went to the pharmacy and picked up the medications and brought them back to the community. The facility was advised by the pharmacist to not start the medication until the following morning. R1 started both medications on 8/21/2025. Typically, R1 manages their own medications, but was confused and apprehensive on the required taper, so the facility assisted. It was determined that the facility dispensed R1’s medication to them as directed by the pharmacist. The medications were delayed as a result of the physician’s office not communicating efficiently with the pharmacy and facility. This was out of the control of the facility. This allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated. No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of the report was provided to Executive Director Nicole Braswell and Rosanna Larsen- Burrill - Business Services Director.the state’s words, verbatim · CDSS document, Sep 30, 2025 · control 59-AS-20250821085212

Type of visit: Required - 1 Year

06/16/2025 11:20 Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Nicole Braswell and explained the purpose of the visit. LPA Knight and the administrator toured the facility together to ensure the health and safety of residents in care. Assisted Living and Memory Care units were inspected. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas, and dining room. Staff and resident files were reviewed. All employees requiring background checks are cleared. Medication is locked in the medication room. Medication was reviewed. Common area was clean and in good repair. All rooms that were inspected had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. All required postings are displayed within facility. Fire extinguishers fully charged and inspected. Red Bluff Fire Department inspected the fire sprinkler system and smoke detectors in April 2025. This inspection is completed every six months. The fire alarm system is tested each month by maintenance manager. There are no pools/bodies of water are on premises. Last disaster drill was conducted in May 2025 which was a missing person drill. Facility full evacuation drill scheduled for June 2025. The facility has been conducting fire drills every month. Fire drills are conducted by shift. No deficiencies are being being cited as a result of today’s inspection. An exit interview was conducted and copy of report was provided to administrator Nicole Braswell.the state’s words, verbatim · CDSS document, Jun 16, 2025

Allegation investigated: Due to staff negligence, resident has had multiple unwitnessed falls. - SUBSTANTIATED

/10/2025 11:30 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Nicole Braswell. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the administrator, memory care director, and care staff. LPA reviewed the following documents: staff list with telephone numbers, Physician’s report, Admission Agreement, needs and services plan for 3 residents, staff schedule, related incident reports. Continued on LIC9099-C Substantiated Due to staff negligence, resident has had multiple unwitnessed falls. - SUBSTANTIATED It was reported that during rounds staff has found Resident 1 (R1) on the floor three times while motion detectors were supposed to be in place and being properly monitored and responded to by staff. LPA reviewed staff schedules for the month of January 2025. In the memory care unit, there were two care staff and 2 med techs serving both sides of the facility for all shifts. LPA reviewed care plan for Resident 1 (R1) which states that staff is to check on R1 four times per night at 12:00 AM, 2:00 AM, 4:00 AM, 10:00 PM, as needed. Staff are to assist resident to the restroom during nighttime checks to prevent falls and reposition as needed. Ensure resident has nonskid socks on all night and verify bed alarm is turned on at all times when resident is in bed. R1 has been using various forms of fall alarms (pressure alarms, motion detectors) since March 2024. LPA reviewed the following incident reports related to Resident 1 (R1): 02/23/2023 12:09 AM R1 was found on their back in the bathroom by care staff while doing rounds. R1 was complaining of back pain and was sent to the ER for further evaluation. R1 was admitted to the hospital for treatment of acute urinary tract infection, acute left closed rib fracture. This incident occurred before R1 started using an alarmed monitor of any kind. 07/20/2024 1:30 AM care staff heard R1 calling for help. Staff found R1 in their bathroom on the floor. A Med Tech examined R1 for injury and found that R1 had two minor cuts to their right elbow. Med Tech provided first aid. 01/05/2025 10:30am R1 was found on the floor by care staff doing rounds for shift change. R1 transported to ER and examined. There were no acute findings noted. R1 returned to the facility the same day for continued monitoring and R1 was moved closer to the common area and med tech room. Continued on LIC9099-C On 01/28/2025 LPA conducted a case management visit at the facility related to a staff member who was terminated for turning motion detector sensors away from the beds of residents who are at risk of falling. LPA confirmed that this staff started working at the facility on 11/15/2024 and was terminated from employment on 01/22/2025. LPA reviewed staffing schedules for the month of January 2025 and confirmed that this staff did not work in the memory care unit of the facility on 01/05/2025 which is the date of a reported unwitnessed fall for R1. This staff was not employed by the facility on 02/23/2023 or 07/20/2024 when the two prior unwitnessed falls occurred for R1. R1 has had three unwitnessed falls over the course of three years. One of the falls occurred prior to the facility implementing motion detectors / pressure alarms for R1. Two of the falls occurred after the use of motion detectors / pressure alarms for R1 were implemented. On 07/20/2024 staff heard R1 calling for help and on 01/05/2025 staff found R1 on the floor during rounds. There is no mention of staff hearing or responding to motion or pressure alarms in either of these incident reports. Staff interviewed stated they can clearly hear the alarm when a motion sensor or pressure alarm is triggered. There is no reasonable explanation as to why staff did not respond to installed motion sensor and pressure alarms to assist the resident as soon as the resident got out of bed and instead found the resident on the floor on these dates. LPA has not determined that staff were necessarily negligent, but has determined that staff require more training related to the use of fall monitors and pressure alarms. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Nicole Braswell. Licensee does not ensure resident's fall monitors are in good repair. - UNSUBSTANTIATED It was reported that motion detectors and receiving equipment are not being properly installed, adjusted, and maintained. 02/10/2025 During an unannounced visit Licensing Program Analyst (LPA) Rebecca Knight toured the facility and inspected motion sensor and pressure alarms in the memory care unit. There are a total of two rooms with motion sensors and one bed that has a pressure alarm. LPA observed noise boxes located at the top of the fire doors in the unit. When LPA entered room 201 and moved in front of the motion detector the noise box sounded an alarm. When LPA entered room 203 LPA observed a bed to the right of the room. Administrator pulled back the covers and a pressure alarm was present. Administrator pushed down on and lifted her hand and LPA heard an alarm sound. LPA entered Room 215 and observed a motion detector, When LPA moved in front of the motion detector the noise box sounded an alarm. LPA reviewed care plan for Resident 1 (R1) which states that staff are to verify bed alarm is turned on at all times when resident is in bed. All staff interviewed confirmed that they can clearly hear the alarm when the pressure alarm or motion sensor detectors are triggered. Administrator stated it is in the resident care plans for the staff to check the motion detectors and pressure alarms every shift and the maintenance director checks the batteries and noise boxes every day. It was determined that the motion sensors and pressure alarms are properly installed and maintained. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to administrator Nicole Braswell.the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 59-AS-20250204154238

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 24, 2025

87411(a) Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on document review and interviews the licensee did not prevent Resident 1 from falling two times while motion detectors/ pressure alarms were in place. This poses a potential Health, Safety and Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 10, 2025

Plan of correction: Licensee agrees to conduct staff training on the requirement to monitor and respond to residents who have motion detectors and/or pressure alarms in place. Licensee shall submit staff sign in sheet and training content to LPA as proof of correction. Due date for POC is 04/24/2025.

Type of visit: Case Management - Incident

01/28/2025 01:00 PM Licensing Program Analysts (LPAs) Rebecca Knight and Kayla Adkison conducted an unannounced case management visit and met with administrator Nicole Braswell. Today’s visit is regarding an incident report that was submitted to licensing on 01/21/2025 regarding an incident that occurred the same day at 4:00 AM. It was reported that a shift supervisor reported to administrator that a care staff had turned motion detector sensors away from the beds of residents who are at risk of falling. This same staff left a high-risk resident on the toilet unattended after this staff person had been previously counseled to ensure that a staff was with this resident at all times. The same morning this staff left an all-purpose cleaner in the memory care kitchen area and the shift supervisor found a resident spraying the cleaner into their mouth. LPA reviewed first aid measures for the all-purpose cleaner which had been submitted with the incident report. The document states if the solution is swallowed the person should rinse their mouth and get medical attention if symptoms occur. Administrator stated the facility sent the resident to the ER for evaluation, poison control and the resident’s POA were contacted. The facility has ensured that the motion sensors in the residents’ rooms have been fixed. In order to prevent this from occurring again the facility has terminated the staff person. On January 23, 2025, the facility held an all staff meeting and reiterated the importance of keeping chemicals locked in a secured area when not in use, talked about high-risk resident care and interventions, and resident neglect. No deficiencies were issued as a result of today’s visit. A copy of the report was provided to administrator Nicole Braswell.the state’s words, verbatim · CDSS document, Jan 28, 2025

Allegation investigated: Staff does not ensure resident's fall monitors are in good repair. – SUBSTANTIATED

/17/2024 11:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Nicole Braswell. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the administrator, memory care director, and care staff. LPA reviewed the following documents: staff list with telephone numbers, Physician’s report, Admission Agreement, care plan, care notes for 1 resident, related incident reports. Continued on LIC9099-C Substantiated Staff does not ensure resident's fall monitors are in good repair. - SUBSTANTIATED It was reported that Resident 1 is supposed to have fall monitors on their clothing and bed but the monitors were not present. LPA reviewed R1’s care plan which states “motion detector, must carry at all times. Verify Motion Alarm Is in the MC med room. 2. Make sure its charging. Med Techs Charting. Executive Director stated R1 has been using fall monitors since March 2024. The family purchased a fall monitor for R1 to wear, this fall monitor mistakenly went through the laundry and the facility reimbursed R1’s responsible party for the ruined monitor. The facility installed a motion detector in R1’s room that reports to the Med Tech laptop. Memory Care Director (MCD) stated R1’s personal fall monitor got washed, they spoke to R1’s RP and explained what happened. They planned to order a new fall monitor but it was taking too long. MCD told RP they would refund the money for the monitor and RP agreed to this. It was determined that the facility washed R1’s clothing with their fall monitor still attached to their clothing which damaged the fall monitor and rendered it non-operable. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation that staff does not ensure resident's fall monitors are in good repair is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Nicole Braswell Resident sustained an unexplained fall and was left on the floor for an extended period of time. – UNSUBSTANTIATED. It was reported that Resident 1 fell and it took several hours before they were assisted. LPA reviewed care plan for R1 which states that R1 has a high fall risk [ADL's/Mobility and Transferring]. R1 has history of falls and has poor safety awareness. Staff are to provide full assistance to resident with walking needs for short distance only. Assist in morning and night during wake-up and bedtime. Nighttime checks- four times per night at 12:00 AM, 2:00 AM, 4:00 AM, 10:00 PM, as needed. LPA reviewed an internal incident report which states on 07/20/2024 at 1:30 AM care staff heard Resident 1 (R1) calling for help. Staff found R1 in their bathroom on the floor. A Med Tech examined R1 for injury and found that R1 had two minor cuts to their right elbow. Med Tech provided first aid. R1 could not recall how or why they fell. Staff notified R1’s physician, responsible party, and the Executive Director of the incident. During staff interviews it was learned that staff had done rounds 15 – 30 minutes prior to the fall. Staff asked R1 if they needed to use the restroom and R1 declined. 15 minutes later staff were in the room next door to R1 when they heard R1 call out. Med tech provided first aid for a small cut on R1’s elbow. Executive Director stated R1 fell in their bathroom on 07/20/2024. R1 had a small cut on their right elbow as a result of the fall. R1 was found by care staff. Memory Care Director (MCD) stated staff found R1 at about 1:15 AM. It was determined that during rounds staff had checked on R1 15 minutes before R1 called out for help. The allegation is unsubstantiated. Continued on LIC9099-C Facility is not following admission agreement and is overcharging resident in care. - UNSUBSTANTIATED It was reported that the facility is overcharging Resident 1 (R1). LPA reviewed R1’s admission agreement that states “Future adjustments to the Base Rent require 60 days' prior written notice to the resident and/or resident’s legal representative which will include the reason for the increase, the amount of the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident, for which the resident or resident’s representative will be given a two day written notification. Evaluation:” The Service Level Fee shall be reviewed 30 days after the Resident's move-in and then quarterly thereafter, although the Community reserves the right to review the Service Level Fee on a shorter interval when appropriate given changes in the level of service required by the Resident. Future adjustments to the Service Level Fee will take effect at any time following a Growth & Wellness Plan review.” Executive Director stated Since R1 returned from their last stay in rehab they did come back to the facility at a higher level of care. Per the admission agreement changes to care change the monthly fee. Memory Care Director stated before R1 returned to the facility from a stay in rehab she spoke with R1’s responsible party (RP) and explained that there would be an increase in monthly fees. The RP signed off on the updated Wellness Plan for R1. It was determined the facility adhered to their admission agreement. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to administrator Nicole Braswell.the state’s words, verbatim · CDSS document, Sep 17, 2024 · control 59-AS-20240806135627

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Oct 2, 2024

87217(b) Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement is not met as evidenced by: Based on document review and interviews the licensee did not prevent the residents’ personal fall monitor from being laundered and rendered inoperable as a result. This poses a potential Health, Safety and Personal Rights risk to clients in care.the state’s words, verbatim · CDSS document, Sep 17, 2024

Plan of correction: Licensee agrees to replace the ruined fall monitor or refund the cost of the fall monitor to the resident’s responsible party. Licensee refunded the cost of the fall monitor to RP on September 2024 statement. The plan of correction has been completed.

Type of visit: Case Management - Incident

09/10/2024 12:45 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Nicole Braswell. Today’s visit is regarding incident reports that have been submitted by the facility regarding several falls that occurred at the facility over the past 6 weeks. The purpose of the visit was for LPA to have a discussion and provide resources. Administrator stated the facility has increased their staffing in memory care, residents who are high fall risk have motion sensors in their rooms. Next month Butte Home Health is coming in to do a training on transfers, falls, and mobility at an all staff training. In order to prevent this from occurring the facility will conduct a fall prevention training with all staff. Administrator will submit a copy of the facility’s fall prevention plan to LPA. LPA referred administrator to ​​​​​​​​​StopFalls Sacramento Coalition for additional resources in fall prevention. https://dhs.saccounty.gov/PUB/StopFallsSacramento/Pages/Stop-Falls-Sacramento-Coalition.aspx No deficiencies were issued as a result of today’s visit. A copy of the report was provided to administrator Nicole Braswell.the state’s words, verbatim · CDSS document, Sep 10, 2024

Type of visit: Required - 1 Year

06/06/2024 12:15 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Nicole Braswell and explained the purpose of the visit. LPA Knight and the administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas, activity rooms, yards, and dining room. Staff and resident files were reviewed. All employees requiring background checks are cleared. Common area was clean and in good repair. 9 of 10 bedrooms that were inspected had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Medication is locked in the medication room. All required postings are displayed within facility. Fire extinguishers fully charged and inspected. Johnson Controls conducted 20 year inspection and UL testing on sprinkler system in November 2023. Red Bluff Fire Department inspected the fire sprinkler system and smoke detectors on April 23, 2024. There are no pools/bodies of water are on premises. Last disaster drill was conducted in May 2024 which was a fire drill. Facility full evacuation drill scheduled for June 2024 with the local fire department. The facility has been conducting fire drills every month. A deficiency is being being cited as a result of today’s inspection and is included on the attached LIC8-9-D. LPA observed that 1 of 10 resident rooms does not have a bed, but does have a recliner that the resident prefers to sleep in. LPA has suggested that the facility request an exception specific to this resident's choice to sleep in a recliner. Exit interview conducted and copy of report was provided to administrator Nicole Braswell.the state’s words, verbatim · CDSS document, Jun 6, 2024

Type of visit: Case Management - Deficiencies

05/21/2024 10:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Nicole Braswell. Today’s visit is regarding an incident that occurred on 05/20/2024 and was reported to licensing by the facility the same day. It was reported that on 05/20/2024 am, Administrator received a call from the branch manager at a local bank regarding two checks in the amount of $5000.00 each that had been cashed by Staff 1 (S1) that were from Resident 1 (R1) account. R1 states they gifted S1 the money because S1’s had been asked to leave their apartment, and S1 needed a deposit, first and last months' rent to move into a new place. Administrator called the Red Bluff Police Department (RBPD) immediately to investigate. Officer from RBPD responded and interviewed R1 to get their side of the story. Officer then interviewed S1 to get their side of the story. Officer returned to the community and informed administrator that S1 was being charged with felony dependent/elder abuse by fraud. Officer also spoke with R1 to inform them of these charges. Employee was suspended immediately and subsequently terminated from employment. As a result of the investigation it was determined that Staff 1 (S1) accepted a substantial amount of money from a resident in care under false pretenses which constitutes financial and mental/emotional abuse. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation that staff financially and mentally/emotionally abused a resident is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Nicole Braswell.the state’s words, verbatim · CDSS document, May 21, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(A)(8) · Plan of correction due date: Jun 4, 2024

Additional Personal Rights of Residents in Privately Operated Facilities (a)(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on document review and interviews the licensee did not protect R1 being financially abused by S1 resulting in significant financial loss to R1 as well as emotional abuse. This poses an immediate Health, Safety and Personal Rights risk to clients in care.the state’s words, verbatim · CDSS document, May 21, 2024

Plan of correction: Licensee agrees to conduct staff training for all current staff regarding the facility policy of accepting gifts and gratuities of any kind from residents in care and the consequences they will face if they do so. Additionally licensee will provide EAP information for staff to access if they are in need of financial and/o remotuonal counseling resources. Licensee shall submit staff sign in sheet as proof of correction.

Allegation investigated: Resident sustained a fracture while in care due to lack of care/supervision. - UNSUBSTANTIATED Staff are not properly dressing the residents. - UNSUBSTANTIATED Staff are locking the residents in their bedrooms. - UNSUBSTANTIATED Staff do not ensure a resident is being properly fed while in care. - UNSUBSTANTIATED

/12/2024 12:00 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Nicole Braswell. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the administrator, memory care director, two med techs and one care staff. LPA reviewed the following documents staff list with telephone numbers, Physician’s report, Admission Agreement, care plan for 4 residents, related incident reports, memory care staff schedule for the months of January through February 2024. Unsubstantiated Page 2 Resident sustained a fracture while in care due to lack of care/supervision. – UNSUBSTANTIATED It was alleged that a resident was left unsupervised and sustained a fall with injury as a result. LPA reviewed an incident report dated 02/03/24 in which it was reported that at 1:00 PM Resident 1 (R1) had a witnessed fall in the dining room resulting in a left hip fracture. Resident stood up from the dining table and was starting to walk with her walker when she lost her balance and fell backwards. Staff was unable to get to R1 in time to assist with her fall. R1 is independent with transfers and mobility with her four wheeled walker. Resident did hit her head on the wall after she fell and did not lose consciousness. Resident was able to get up from the floor with assistance and take small, short steps. Resident's pain had increased shortly after and was then sent to the ER for evaluation. Resident was taken to ER via ambulance. Persons contacted: Monica Gralian PA-PCP, Jack- son, Nicole Braswell LVN- Administrator, Nancy Martinez- Wellness Director. During staff interviews 3 of 3 staff stated the fall occurred in the dining room and was witnessed by staff. 3 of 3 staff stated R1 lost her balance holding her walker. Memory care director stated R1 appeared to have gotten up from the table and she fell back. Staff saw it and tried to run to help her but didn’t make it in time. Administrator stated It was a witnessed fall. R1 was getting up from the table to leave the room and a caregiver was there but was escorting another resident. The caregiver heard R1 call out and she turned around but was not able to get to R1. Staff contacted the administrator when R1 initially fell, she said she was not in pain. Administrator asked staff to call the family and ask what they would like. About an hour went by and the administrator didn’t hear anything. The med tech told the administrator that R1 had increased pain, so they called EMS. The family had called back and said, “No don’t send her out.” The med tech told the family that they were making the decision to send her out. It was determined that the resident was in the dining room with staff present when they fell, the fall was witnessed by staff. The resident was not left unsupervised. The facility followed their protocol of notification. The allegation is unsubstantiated. Continued on LIC9099-C Page 3 Staff are not properly dressing the residents. – UNSUBSTANTIATED It was alleged that residents are wandering around half dressed. 3 of 3 staff stated they help the residents get dressed, a lot of them don’t understand how to get dressed themselves, if a resident takes off clothes they are re-directed. Memory care director stated Every morning they (staff) assist them. Some residents prefer to be in pjs all day, but we try to dress them as appropriately as possible. Administrator stated Most of them require get up assistance and staff go in and make sure they have appropriate clothes on. Some will wander out of their room with no pants, so we usher them back and help them get dressed. It was determined that staff assist residents in getting dressed and if a resident attempts to disrobe in the common area they are re-directed. This allegation is unsubstantiated. Staff are locking the residents in their bedrooms. – UNSUBSTANTIATED It was alleged that residents are being put in their rooms and the door being shut and locked behind them. Staff interviews revealed resident rooms are locked to keep other residents from going into other resident’s rooms. You have to use a key from the outside to unlock the doors but as soon as you turn the handle from the inside the doors open. Memory care director stated There are a few that were requested by families because they didn’t like other residents going into their rooms but that is not the norm. The doors lock from the inside and a resident can leave the room without unlocking the door. Administrator stated The doors can lock, we do have a couple of residents that they lock just from the outside and not the inside because they have aggressive behaviors. They can open the doors from the inside if the door is locked from the outside. It was determined that resident rooms have locks on them to deter other residents from entering rooms that are not theirs. All resident room doors can be opened by the residents from the inside without having to unlock the door. This allegation is unsubstantiated. Continued on LIC9099-C Page 4 Staff do not ensure a resident is being properly fed while in care. – UNSUBSTANTIATED It was alleged that residents are left in bed and do not get to eat dinner. 3 of 3 staff interviewed stated if a resident doesn’t want to come to the dining room, they bring them a tray to their room. 3 of 3 staff stated that snacks are available to the residents. Memory care director stated We take them a tray and go back and check to make sure it has not gotten cold. If it’s someone that needs eyes on while eating the staff will stay there with them. We do snack at and any time in between if they are hungry, we will give them something. Administrator stated If they chose to stay in bed, we will bring a tray in their room and go back around and check to make sure they are eating while they are in their room. It was determined that if a resident chooses to stay in bed staff bring them a meal tray, snacks are offered and available to residents. The allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to administrator Nicole Braswell.the state’s words, verbatim · CDSS document, Mar 12, 2024 · control 59-AS-20240205112721

Allegation investigated: Facility staff are not ensuring that an appropriately skilled professional is assisting the resident with injections. - UNFOUNDED

/15/2024 1:00 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Nicole Braswell. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the administrator and requested the following documents: staff list with telephone numbers, Physicians Report, care plan, physician’s order for medication for 1 resident. Continued on LIC9099-C Unfounded Facility staff are not ensuring that an appropriately skilled professional is assisting the resident with injections. - UNFOUNDED LPA reviewed a physician’s order dated 10/23/2024 ordering injections to be administered once every two weeks for Resident 1 (R1). During the course of the investigation, it was learned that a home health agency was contracted to administer an injection to R1 twice a month starting in October 2023. The home health agency inadvertently discharged the resident from services on 01/09/2024 and discontinued the injections without informing the family or the facility. The facility did not manage this medication for the resident as the facility is not allowed to administer injections. LPA was informed by complainant that the complaint should have been made against the home health agency, not the facility. This allegation is unfounded. This agency has investigated the complaint alleging the facility failed to ensure that an appropriately skilled professional was assisting a resident with injections. As a result of the investigation the agency has found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted. A copy of the report was provided to administrator Nicole Braswell.the state’s words, verbatim · CDSS document, Feb 15, 2024 · control 59-AS-20240124093740

Type of visit: Case Management - Incident

10/10/ 2023 1:00 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Sue Todd. Today’s visit is regarding an incident that occurred on 10/08/2023 and was reported to licensing on 10/10/2023. It was reported that on 10/08/2023 at 5:24 PM Resident 1 (R1) was getting up from a table in the dining room and they lost their balance, fell backwards and hit the back of their head on a table. R1 did not lose consciousness and was awake and responding. R1 sustained a laceration to their right elbow. R1 was transported to ER for evaluation and subsequently admitted for acute hyponatremia, acute ground level fall with head strike and elbow contusion. During the course of the investigation, it was learned that R1 was hospitalized for low sodium level, not related to R1’s head strike. R1 is currently still at the hospital where they are working on getting R1’s sodium regulated. In order to prevent this from happening again the facility has requested home health to come in to ensure R1 has no further issues. Facility is going to request physical therapy for R1 due to a recent issue with getting up and down from a seated position. No deficiencies were cited as a result of today’s visit.the state’s words, verbatim · CDSS document, Oct 10, 2023