Meadow Oaks of Roseville

Allegation investigated: Resident is being charged for services not provided

Licensing Program Analyst (LPA) Graham Gunby arrived on 06/30/2026 to deliver findings to a complaint the department received on 03/13/2026. LPA met with Executive Director, Sheri Kimbro, and explained the purpose of this visit. During the investigative process The Department conducted document review, interviewed staff and relevant parties. R1 provided the facility with a 30-day termination notice on 01/01/2026, moving out on 01/31/2026. R1's account was charged $3,600 on 02/01/2026. The facility returned the Feburary charge on 03/14/2026. Even though R1's account was charged, services were not provided and a refund was given to the resident. 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. Nothe state’s words, verbatim · CDSS document, Jun 30, 2026 · control 59-AS-20260313122216

Allegation investigated: Staff speaks inappropriately at residents Staff do not respond to residents call buttons in timely manner Staff are handling residents in a rough manner

Licensing Program Analyst (LPA) Graham Gunby arrived unannounced on 03/20/2026 to complete and deliver findings to a complaint received on 12/15/2025. LPA met with Executive Director, Sherri Kimbro and explained the purpose of the visit. Throughout the course of the investigation, the department conducted interviews and record reviews. Please continue to LIC9099C.. Unfounded Staff speaks inappropriately at residents Based on interviews with staff and residents to conduct the investigation. LPA interviewed staff and Executive Director in which they stated they have not observed staff talking inappropriately to residents. LPA interviewed relevant party in which they stated current staff do not talk inappropriately to residents but in the past staff have spoken to residents in appropriately. Relevant party was unable to give names of staff or specific incidents. Due to the information gathered LPA finds allegation to be UNFOUNDED. Staff do not respond to residents call buttons in timely manner Complaint alleges that Staff are not answering residents' call buttons in a timely manner. Based on an observation of facility records, LPA could not prove or disprove the allegation. On 12/18/2025 LPA reviewed call button logs and observed staff are responding to call buttons within a timely manner. In addition, LPA conducted interviews and learned of no concerns as it relates to answering of the call bells in a timely manner. LPA could not corroborate the allegation, therefore the LPA finds allegation to be UNFOUNDED Staff are handling residents in a rough manner Based on interviews that was conducted with residents, residents stated that they did not witness staff handling residents in rough manner and they were satisfied with staff's care at the facility. Staff interviewed stated that they have not observe other staff being rough with residents in any manner. Staff interviews indicated that staff treat all residents with respect and dignity and work at facility in a professional manner. Furthermore, department did not observe any kind of bruising, body marks or any other injury related to staff being rough with residents in facility’s records and documentation. Based on gathered information, this allegation was found to be UNFOUNDED. A finding that the allegations are Unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, Mar 20, 2026 · control 59-AS-20251215091659

Type of visit: Required - 1 Year

On 02/26/2026, Licensing Program Analyst (LPA) Graham Gunby arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Executive Director (ED), Sheri Kimbro, and explained the purpose of the visit. LPA and staff toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, residents' bedrooms, bathrooms, kitchen, and courtyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. Toxic and cleaning supplies locked and is inaccessible to residents in care. Medications are locked and inaccessible to residents in care. The hot water temperature was measured in the bathroom at 113 degrees Fahrenheit. First aid kit was complete. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguishers were last serviced on 10/15/2025. Fire drill was last conducted in January 2026. LPA observed required Licensing posters posted throughout the facility. LPA reviewed a total of eight (8) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of five (5) staff record. Staff training were completed. No deficiencies being cited during today's inspection. Exit interview conducted with Executive Director, Sheri Kimbro, and report provided.the state’s words, verbatim · CDSS document, Feb 26, 2026

Type of visit: Case Management - Other

On 12/15/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Generations Program Director . On 12/12/25, the department received an incident report of a fall by R1. The report stated that R1 had an unwitnessed fall on 12/8/25. LPA reviewed the internal incident report made by the responding med tech (S1). The med techs report noted R1 some have some minor pain and R1 stated they did not wish to have a medical assessment. Med tech failed to follow program policy to notify emergency responders for an unwitnessed fall with report of pain. Med tech also failed to notify management of the fall. On 12/10/25, the incident was reviewed by management and R1 was assessed further by facility staff. On 12/10/25 R1 was found to express pain with coughing and deep breathing. R1 continued to express resistance to medical care. On 12/11/25, a family member brought R1 to urgent care where it was found that R1 had a rib fracture. R1 did not experience significant loss of function or other health risk. Therefore, facility staff did not notify 9-1-1, or management and this resulted in a delay in care to R1's injury. The responding med tech is currently removed from that role pending further training. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. with Rena Gabriel. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Dec 15, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jan 12, 2026

Incidental Medical and Dental Care (a) (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.This requirement was not met based on written report and interview. This posed a potential risk to the resident.the state’s words, verbatim · CDSS document, Dec 15, 2025

Plan of correction: As this incident showed a lapse in staff following policy and occurred at a time of some management position vacancies, The licensee will do retraining with med techs and review procedures in place with incoming managers to insure policies in place are followed. POC to provide proof of training and management review of incident communication policies by the POC date of 1/12/26.

Type of visit: Case Management - Other

On 9/25/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit met with Director/ administrator. On 9/24/25, the department received a death notification for R1's unexpected death on 9/18/25. R1 was admitted to the community on 9/17/25. LPA interviewed administrator and resident care director. LPA reviewed and received resident records. Additionally, LPA received contact information for R1's representatives and staff contact present on the noc shift 9/17-9/18/25. LPA will request additional records as needed. While present LPA also discussed another resident issue unrelated to this incident As a result of today’s inspection, no deficiencies were noted. Report reviewed with administrator and report copy provided.the state’s words, verbatim · CDSS document, Sep 25, 2025

Type of visit: Case Management - Other

On 8/19/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Administrator . On 8/8/25 the department received an incident report regarding R1. R1 had a fall with injuries. LPA received requested records and conducted interviews. As a result of today’s inspection, no deficiencies were noted. LPA will continue to gather additional information. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Aug 19, 2025

Type of visit: Case Management - Other

On 5/22/25, Licensing Program Analyst (LPA), Kevin Mknelly, and Licensing Program Manager, Maribeth Senty were present for a Non-compliance Conference via Microsoft Teams today with Zachary Butcher, Nathan Condie, and others who the licensee invited to attend. This meeting was called to review the status of facility's compliance plan that was established on 2/6/25. Topics discussed during this meeting were: Continued incidents of non-compliance related to some of the topics addressed in the compliance conference of 2/6/25. Ways in which the existing compliance plan will be enhanced to address the medication errors identified on 3/14/25 and 3/26/25 and well as issues identified in monthly audits such as communication with physicians, medication records and medication refills In today's meeting, the licensee agreed to submit an amended quality assurance policies and procedures that have been added or developed as a result of ongoing issues noted. A follow-up conference is to be scheduled, as needed, based on compliance performance. A copy of this report will be provided to the facility via email. A copy will be signed and returned to CCLD.the state’s words, verbatim · CDSS document, May 22, 2025

Type of visit: Case Management - Incident

On April 10, 2025, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with acting Executive Director . On 4/2/25, the department received an incident report of a medication error involving R1 on 3/26/25. On 3/26/25, R1 received a dose of hydrocodone at approximately 5:12 PM, from Generations Program Director (GPD), S1, who was filling in as PM shift met tech (MT). The report stated that the hydrocodone had been discontinued on 3/24/25, due to resident's physician determining that hydrocodone was causing R1 hallucinations. Records review and interviews conducted that on 3/26/25, R1 received a new medication to replace hydrocodone, Tramadol, at 8 AM, 2 PM and again at 8 PM. Interviews found that the error was not found until 3/27/25. Hospice was notified of the error. Interviews found that the main contributing factor for the error was a lapse in following of existing communications and documentation policies and procedures. R1 was not known to have been adversely effected by the error. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Civil penalty assessed. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Apr 10, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87456(a)(4) · Plan of correction due date: Apr 11, 2025

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met based on records and statements which found R1 received a disconitnued medication. This posed a potential risk to R1.the state’s words, verbatim · CDSS document, Apr 10, 2025

Plan of correction: To date, the licensee has amended the notification process for med changes to be directly emailed to ED, Nurse and GPD. Licensee agrees to increase and proceduralize MT- MT shift notes details, develop a med change alert system to compensate for lags in time from order changes to new MAR and provide retraining on newly established and existing procedures for medication communications. Documentation of procedure and or changes and date of staff training will be submitted by POC date 4/11/25. Training to be completed by 4/15/25

Type of visit: Case Management - Incident

On March 27, 2025, Licensing Program Analyst, Kevin Mknelly arrived at 10:20 AM and met with Administrator/ Director, Nathan Condie. The purpose of the visit was to review recently reported incident. On 3/20/25, the department received an incident report of medication error for R1 on 3/14/25. It was reported that medication technician (med tech) S1 mistakenly administered a once per day blood pressure medication at 8:00 PM though the medication had already been correctly administered on 3/14/25 at 8:00 AM. The error was reported to the facility's nurse and monitoring was increased for the resident. At approximately midnight, R1's blood pressure triggered a call to emergency responders. Responders monitored the resident and resident did not require hospitalization. R1 sustained no further negative effects. A deficiency is noted for this medication error. Falls by R2 were also discussed. R2 experience 4 falls, some with minor injuries, between February and March 2025. On 3/7/25, R1 was admitted to rehabilitation for improved conditioning. While in rehab., R1 passed away from causes unrelated to care at this facility. No deficiency was cited for this issue. While at the facility, LPA and Director observed and discussed strategies for managing residents with wandering and exit seeking. Issues discussed involved possibilities of limiting egress from certain doors from memory care to the courtyard. LPA encouraged Director to discuss possible alterations to exit with the area fire Marshall for approval. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed- copy of the report and appeals rights provided.the state’s words, verbatim · CDSS document, Mar 27, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 28, 2025

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met based on records and statements. This posed a potential risk to R1.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Licensee responded and addresses to error and provided necessary monitoring and response of the resident. After review of the incident, licensee made changes to recording and highlighting of hand written MARs for new residents. This correction was noted during this visit.

Type of visit: Case Management - Incident

On March 11, 2025, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with acting Administrator, Nathan Condie . On March 6, 2025, the department received an incident report from the facility. The report was regarding R1 leaving the memory care enclosed patio by climbing over the fence with the use of patio chair at approximately 7:40 AM on March 6, 2025. R1 had moved into the facility on March 3, 2025 and was still having difficulty adjusting to this new home. LPA reviewed facility records and conducted interviews with the Administrator and the med tech who was working on the morning of March 6, 2025. It was found that since admission R1 was not regularly participating in activities and continued to state a desire to leave. On the morning, R1 exited the door by her room to the patio. It was found that the batteries were low on the door alarm and the alarm was low and weak. Caregivers did not hear the alarm when R1 exited. R1 then moved patio furniture to a nearby fence. R1 scaled the fence, fell to the other side and was first responded to by workers on the other side of the fence. Caregivers then responded, R1 received medical assistance for an abrasion. LPA observed R1 today though R1 declined to be interviewed. Administrator reported that R1 is more emotionally stable and 1:1 observation has been lifted. Records review found that there were incidents and actions of R1, who has a dementia diagnosis and behavioral expressions of inappropriate behavior, confusion, aggressive behavior, depression and self harm on a physician's assessment dated March 3, 2025. ...report continued Internal staff communication documents reviewed and in places failed to consistently capture and communicate to managers from shift to shift of R1 status. Though R1 was noted to have increased ambulation instability on 3/4/25 and very confused repeated emergency pull cord use on 3/5/25, R1 continued to be intermittent checks. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Mar 11, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c(4) · Plan of correction due date: Mar 25, 2025

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(4) There is an adequate number of direct care staff to support each resident’s ... safety ...needs as identified in his/her current appraisal and demonstrated behaviors This requirement was not met based on records and interviews that found adequate number of staff were not present to implement R1's care need. This posed an immediate risk to R1.the state’s words, verbatim · CDSS document, Mar 11, 2025

Plan of correction: LPA observed that the immediate safety issues for R1 have been corrected by R1's wandering behaviors have reduced, door alarms are fully operational after battery replacement, staff pagers and walkie-talkies have been have been upgraded. Administrator agreed to discuss / review the possibilities of reducing exit possibilities during times of day. Feasibity and plan to be submitted. Administrator will review all documents pertaining to this incident and submit updated written communication forms. POC due 3/25/25

Type of visit: Case Management - Other

On February 13, 2025, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Administrator . The visit conducted today is to review the amended report created in 1/14/25. On 1/14/25 an incorrect regulation was cited for the CCR 87469(c)(3) Advanced Directives and Requests Regarding Resuscitative Measures. As the deficiency did occur but was incorrectly cited, the deficiency was removed from the 1/14/25 report and is being re-issued at this time. The plan of correction for the deficiency has been completed. No further action is required by the licensee at this time. While present LPA reviewed a medication error that occurred on 1/31/25. A plan of correction had already begun. The resident was uneffected by the error and supervisory action has been initiated for the staff. As a result of today’s inspection, no new deficiencies were noted. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Feb 13, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87469(c)(3) · Plan of correction due date: Feb 14, 2025

Advanced Directives and Requests Regarding Resuscitative Measures (c)(3)(c) (3) Specifically for a terminally ill For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1). This requirement was not met met based on records review and statements that found resident with an unwitessed fall did not receive emergency response. This posed an immediate risk to the resident.the state’s words, verbatim · CDSS document, Feb 13, 2025

Plan of correction: This deficency was originally cited on 1/14/25. This deficiency is being delivered with an amended LIC809 D for 1/14/25. This deficency's POC has been cleared.

Type of visit: Office

On 2/6/24, Licensing Program Analyst (LPA), Kevin Mknelly, Regional Manager, Alycia Rayner and Licensing Program Manager, Maribeth Senty were present for a Non-compliance Conference via Microsoft Teams today with Mike Zueg, Zachary Butcher, Nathan Condie, Jessica Sanders and others who the licensee requested. This meeting was called due to significant deficiencies noted at the facility from May 2024 to Present. Topics discussed during this meeting were: · Administrator qualifications · Incidental Medical and Dental Care Services violations · Personal Rights violations · Internal and external communications systems and audits · Staffing and staff training · Observation of Resident-change in condition procedures for administrator and staff. In today's meeting, the licensee agreed to the drafted non-compliance plan as outlined in LIC 9111. A copy of this report will be provided to the facility via email. A copy will be signed and returned to CCLD.the state’s words, verbatim · CDSS document, Feb 6, 2025

Type of visit: Case Management - Other

On 1/29/30, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management and met with Regional Clinical Specialist (RCS) who requested a meeting with LPA to assist in resolving outstanding plans of correction. A licensee representative had asked for assistance. LPA and RCS discussed incidents and visits that resulted in citations issued 1/14/25 and 1/22/25 for which plans of corrections have not submitted to date. LPA reestablished time-limes and content needed for outstanding POCs. Licensee, or designee, will email to LPA 1/30/25 to present the plans of corrections for these outstanding A citations be submitted by 2/3/24. Additionally B citation POCs are still due on time. As a result of today’s inspection, no deficiencies were noted. Report reviewed with . Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Jan 29, 2025

Type of visit: Case Management - Incident

On 1/22/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit met with Administrator . On 11/6/24, the department received a Death Notification for R1's passing on 11/4/24 while hospitalized. The notification stated that R1 was sent to the hospital on 11/1/24, approximately 9 AM, for a "declining baseline". R1's death was not expected and R1 was not on hospice care. On 11/14/24, the Department conducted an initial case management visit regarding the death of R1. LPA requested and reviewed R1 records prior to the 11/14/24 visit. LPA received additional records on 11/14/24 as well conducting interviews of resident care director, memory care director and three caregivers. The department also received and reviewed medical records and the death certificate for R1. At this time, the department finds that resident exhibited changes of condition and had not taken several prescribed medications for three days prior to R1’s 11/1/24 hospitalization. The changes and missed medication were not reported to R1’s physician and assistance was not provided to R1 for medical care. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jan 23, 2025

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning …When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician… This requirement was not met based on records and interviews which showed a change of condition not brought to the physician’s attention. This posed an immediate risk to the resident.the state’s words, verbatim · CDSS document, Jan 22, 2025

Plan of correction: Licensee will submit a plan for a review and training of accountable staff for reporting, recording and contacting medical care for changes in conditions- training to be completed within seven days.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Kevin Mknelly and Kayla Adkison arrived at the facility unannounced on 1/22/25 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with Administrator who assisted with the visit. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. Residents interviewed stated no care concerns. LPA reviewed 6 resident files. Files are complete and well organized. 3 of 6 resident service plans did not have signatures for review by resident and or representative. LPA reviewed 5 staff files. Files are complete. 1 of 5 staff did not have documentation of required dementia care training presently at the facility, and advisory was issued. LPA requested Administrator submit: a copy of Admin Cert and LIC 500. A deficiency is being cited as a result of todays inspection. Exit interview conducted with licensee and copy of report left at the facility.the state’s words, verbatim · CDSS document, Jan 22, 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.

Type of visit: Case Management - Deficiencies

**Report amended- a deficiency was removed due to incorrect CCR. Deficiency re-issued 2/13/25.** On 1/14/25, Licensing Program Analyst (LPA) Kevin Mknelly, arrived to deliver incident investigation findings and met with Executive Director. On 5/3/24, while LPA was present to investigate facility reported elopement by R1, on 4/20/24, LPA was notified of R1’s unexpected death on 5/2/24. LPA returned on 5/16/24 to conduct further investigation. LPA requested records related to R1 and conducted staff interviews. Records review for R1 found that R1 sustained a Subdural Hematoma on 1/1/24 following an unwitnessed fall at the facility. Following hospitalization for the injury, Hospice care was initiated on 1/7/24. R1 was also diagnosed to have dementia and documented as a fall risk. Hospice records included recommendation that R1 has standby assist while ambulating. Hospice records stated that on 5/1/24, R1 had a unwitnessed fall from R1’s bed to a fall mat. No injury, pain or agitation was observed at the time of the fall. Medication Technician (Med Tech) S1 reported to Hospice that the fall occurred approximately 1 hour after morning medications. Based on R1’s medication list, the medications R1 was administered included 0.5 mg of Lorazepam (Ativan) , Metroprlol 10 mg, Quetiapine (Seroquel) 50 mg. The administered medications given list possible side effects of drowsiness, dizziness or unsteadiness. On 5/1/24, S1 reported to the Hospice nurse that since R1’s increased current doses of Lorazepam and Quetiapine on 4/26/24, R1 was observed to be sleeping approximately 15 hours per day. Per Hospice records, the reason for Lorezepam listed was for R1’s anxiety and Quetiapine for agitation, restlessness and exit seeking. Records and statements found that on 5/2/24, at approximately 12:00 PM, R1 exited the residence to an enclosed courtyard. Staff, S2, heard the door alarm and went to that exit. S2 was assigned other residents to care for but had witnessed R1 to be very active the morning. S2 observed R1 to be lying in the bark on their left side with R1's right cheek on the ground. S2 stated that R1's wig had fallen off and was on the ground nearby. S2 encouraged R1 to remain where R1 was until med tech (S1) arrived to assess. R1 reported a sore ankle to S2. When S3 and S4 arrived to assist, S2 returned to attend to other residents. On 5/16/24, LPA inspected the area R1 was observed to have fallen on 5/2/24. R1 had fallen to the left after exiting to the courtyard. LPA observed that where R1 had fallen into the landscaping wood chips, the wood chips were approximately 3 inches lower that the surface of the sidewalk. S3 was assigned to R1 the morning of 5/2/24. In interview with LPA, S3 described that R1 “had kept me on my toes” the morning of 5/2/24. S3 stated that on 05/02/24, R1 observed to be occasionally off balance as they R1 moved around the community but had no observed falls. S3 was the second staff to arrive after the door exit alarm sounded. S4 stated that when they arrived to the courtyard, R1 was seated in the wood chips with their back against the wall of the building. S4 reported that they asked R1 if R1 had hit their head and R1 responded yes. Med tech, S1, arrived to assess R1 and determined it was safe to move R1 inside. S3 and S4 provided physical assist escort to R1 as they appeared “unsteady”. R1 was then sat in the common area. Med tech, S1, reported in an interview with LPA that S1 spoke with R1 and did a body check of legs, arms and head. R1 did not report pain and there were no apparent scrapes, bumps or bruises at the time of S1’s assessment. S1 notified Hospice of the fall and report of R1 hitting their head. A Hospice nurse was to be sent to assess R1 and arrived at the facility at approximately 3:00PM. (Note: Medication records and statements received by LPA, indicate R1 received sedating medications between the fall and Hospice’s arrival.) Report continued... S1 was told, by Hospice, to give Acetaminophen (Tylenol) if pain was present. S1 stated that they administered Tylenol to R1, however, LPA checked PRN records and saw no recorded Tylenol dispensed on 5/2/24. S1 stated that S3 and S4 assisted R1 to stand and walk into the common area, past the dining area and then to the couch by the fireplace. S1 stated they though a Hospice aide came shortly after R1’s fall to provide R1 a bath and that there were no reported concern from the aide. S1 did not speak further with hospice before the end of the shift at 2 PM. S1 notified the PM med tech, S5, of the incident and hospice contact. S1 indicated they last saw R1 post bath, sitting on a chair in their room, before S1 left their shift. Hospice Nurse notes for 5/2/24 fall assessment stated: “PATIENT LYING IN THEIR HOSPITAL BED AND AROUSABLE TO VERBAL AND TACTILE STIMULATION. UPON ASSESSMENT, PATIENT VERBALIZED THAT THEIR HEAD HURTS AND FACILITY MEDTECH INSTRUCTED TO ADMINISTER ACETAMINOPHEN FOR PAIN MANAGEMENT. PATIENT ABLE TO MOVE UPPER AND LOWER EXTREMITIES WITHOUT ANY NEW LIMITATION TO RANGE OF MOTION. NO REDNESS NOTED ON THEIR SKIN, NEW BRUISE NOTED TO THEIR RIGHT BUTTOCKS, AND NO SKIN TEAR OBSERVED. LEFT ANKLE IS SLIGHTLY SWOLLEN WITH NO SIGNS OF NONVERBAL PAIN NOTED DURING PALPATION. NO SIGNS OF ANY BUMP ON THE HEAD OBSERVED AS PATIENT MIGHT HAVE HIT THEIR HEAD PER FACILITY.” PM shift med tech S5 reported to LPA that facility medication records did not show only that R1 received their regularly scheduled medications at 2:00 PM. (Note in medication Administration record (MAR for 5/2/24, 2 PM- “H” is documented.) S5 recalls a conversation with a male hospice nurse who had arrived to assesses R1. At approximately 3:00 PM. S5 was told by the hospice nurse, that R1 had a left ankle injury and a right sided "butt bruise". S5 observed R1 to hold their head and squint during the assessment by the Hospice nurse. S5 reminded the Hospice nurse that R1 had had a previous brain bleed at the beginning of the year. Report continued... On 5/2/24, PM caregiver S6 stated in interview with LPA that as S6 was starting their shift, a male Hospice nurse was leaving. R1 was observed to be asleep and in bed. Staff were to check on R1 every 30-40 minutes. S6 understood that Hospice had given R1 "something for agitation". (LPA did not see record of an as needed medication having been given to R1 during their visit on 5/2/24). S6 indicated that they observed when R1 was administered Ativan, R1 may be sleepy for some time. When S6 checked on R1 at around 3:30, R1 had moved from R1's bed and appeared to be resting in a chair in R1's room. S6 checked on R1 again at around 4 PM. S6 found R1 to be slouched on the floor with their arm and head on the side of the bed. R1 appeared to be tremoring and struggling to breath. There was vomit and bowel incontinence on the bed and floor by R1. S6 repositioned R1 to try to provide and open airway. Med tech, S5, was called. Hospice was called by med tech, S5. A female nurse and the male nurse from earlier arrived. LPA asked what the procedure is for an unwitnessed fall and resident hitting their head. S6 said their understanding is that Hospice is to be called if the resident appears “okay”. LPA interviewed Executive Director (ED), Jessica Sanders and asked what the policy is for unwitnessed falls for residents known or suspected to have hit their head in the fall. ED responded that the resident who fell should not be moved and if it is suspected the resident hit their head, 9-1-1 should be called and then hospice notified. Placer County death certificate for R1 identified immediate cause of death as Senile Dementia with other significant conditions of Hypertension and Recurrent falls. Report continued... Based on the evidence found in this investigation, the department finds that the staff did not ensure sufficient care and supervision was provided to resident (R1) and staff did not seek medical treatment in a timely manner for resident in care. R1 was known to need assistance with ambulation due to a history of falls, behavioral expressions and effects of medications. Furthermore, staff interviewed were found to be unclear of facility policy mandating call to 9-1-1 for unwitnessed falls with report of a resident hitting their head or when to call Hospice only. Executive Director and Generations Director was present at the facility yet were not informed or aware of the incident at the time on 5/2/24. It was additionally found during hospice records review that R1 had successfully left the building on 4/5/24 and was found in the facility’s parking lot. There is no record of this incident having been reported to CCLD. R1 had a successful elopement on 4/20/24 for which the facility was cited by CCLD. On 4/26/24, R1 had an attempted elopement where it was noted that R1 was able to get out of the facility and on to the facility grounds before staff responded and R1 returned to memory care. The 4/26/24 incident of R1’s elopement was also not reported to CCLD. Lastly, in this investigation, it was found that Administrator failed to ensure staff resources were available for identified needs of R1, staff were not properly trained for unwitnessed falls procedures, failed to report incidents failed to ensure walkways accessible to R1 were safe given R1’s ambulation deficits. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on health and safety code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted. Report reviewed. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 14, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jan 15, 2025

Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, ...elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by statements and records showing lack of supervision at the time of R1’s fall on 5/2/24. This posed an immediate risk to R1.the state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: Licensee agreed to submit a plan for assessing staffing and staff communication for residents known to have exit seeking behavior. This POC is due 1/14/25. Immediate civil penalty assesses

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(h)(5) · Plan of correction due date: Jan 15, 2025

Administrator - Qualifications and Duties(h) (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs, including those services identified… This requirement was not met based on interviews and records that found R1's supervision regularly did not receive the services of ambulation supervision, staff were unaware of when 9-1-1 was to be called and Admin was unaware of a significant event in the facility. This posed an immediate risk to the residentthe state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: Licensee agrees to submit a plan for review and communication of any incidents or concerns for resident safety issues to be brought to the ED or designee attention in a timely manor. POC by 1/15/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Jan 28, 2025

87211 Reporting Requirements(a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified (D) Any incident which threatens the welfare, safety or health of any resident… This requirement was not met based on interviews and records which found unreported incidents of elopements by R1. This posed a potential risk to resident.the state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: Licensee agrees to submit the procedure of incident, to begin report, to review to submitting to CCLD for all reportable incidents by the POC date of 1/28/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jan 28, 2025

87303 Maintenance and Operation (a) The facility shall be … safe, … and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents. This requirement was not met based on observations which found surface from walkway to landscaping presented an uneven surface for un unsteady, unsupervised resident to fall. This poses a potential risk to residents.the state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: Licensee agreed to to submit the procedure for safety checks of the community grounds to include check lists utilized and persons respibsible for the reviews and corrective actions by the POC 1/28/25.

Type of visit: Case Management - Other

On 12/30/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Executive Director, Jessica Sanders. On 12/27/24, the department received a Death Notification for R1's passing on 12/20/24 unexpectedly. The notification stated that R1 was found by caregiver at 7:50 AM, unresponsive and seated in a recliner in their room. R1's death was not expected and R1 was not on hospice care. LPA requested and reviewed R1 records prior to this visit. LPA received additional records during this visit. LPA also conducted interviews of caregiver who found R1 on 12/20/24, Executive Director and had spoken with family prior to this visit. R1 was least seen by med tech (S2) at 6:30 AM, on 12/20/24. R1 did not appear to be in distress. At 6:30 R1 refused a medication. From records review and interviews, R1 appears to have had a natural death. R1 had a number of co-morbidities. Coroner's report is pending. As a result of today’s inspection, no deficiencies were noted at this time. Report reviewed. Copy of report provided.the state’s words, verbatim · CDSS document, Dec 30, 2024

Type of visit: Case Management - Incident

On 11/14/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Executive Director, Jessica Sanders. On 11/6/24, the department received a Death Notification for R1's passing on 11/4/24 while hospitalized. The notification stated that R1 was sent to the hospital on 11/1/24, approximately 9 AM, for a "declining baseline". R1's death was not expected and R1 was not on hospice care. LPA requested and reviewed R1 records prior to this visit. LPA received additional records during this visit. LPA also conducted interviews of resident care director, memory care director and three caregivers. LPA requested additional records for R1- Initial hand written MAR and physician's medication orders. As a result of today’s inspection, no deficiencies were noted at this time. Report reviewed. Copy of report provided.the state’s words, verbatim · CDSS document, Nov 14, 2024

Type of visit: Case Management - Incident

On 11/6/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Director, Jessica Sanders. On 11/5/24 the Regional Office received incident reports for the following incidents: Incident 1- On 10/30/24, medication technician, S1, notified managers that a medication documentation irregularity was found. The incident involved R1 who was supposed to receive a daily full tab of a controlled medication. The incident report noted that R1 was documented to have received a half tab of the medication instead of the prescribed full tab 10/7/24- 10/30/24. R1 was unharmed as a result. R1's physician was notified and corrective action was taken with the three staff who had made the error. LPA reviewed records and conducted interviews where it was found that staff deviated from facility policies and did not follow medication training that resulted in R1 not receiving medication assistance for medications as prescribed. Incident 2- On 11/3/24, at approximately 1:30 PM, staff discovered R2 to be missing. R2 has a known history of attempts to leave the memory care without physician's recommended assistance when leaving. The care plan in place was for staff to maintain "eyes on" for R2 during waking hours. In this incident it is unknown how R2 left unaccompanied. LPA conducted interviews with R2, Administrator and 2 caregivers that were present on 11/3/24. Interviews found that while staff were aware of R2's exit seeking behaviors, there was not a concrete plan for how the staff present would maintain eyes on R2. On 11/3/24, R2 was found by local police a short way from the facility and was returned unharmed. This is the second such event for R2. It is found that there was not an adequate number of direct care staff to support each resident’s safety needs as identified in his/her current appraisal. The facility has since added additional care staff to PM shifts. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. The citation for insufficient staff for dementia care is the third within 12 months. Civil Penalties are applied. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Nov 6, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: Nov 7, 2024

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(4) There is an adequate number of direct care staff to support each resident’s ... safety ...needs as identified in his/her current appraisal. This requirement was not met based on records and interviews that found adequate number of staff were not present to implement R2's identified care need. This posed an immediate risk to R2.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: Licensee agrees to submit a concrete plan for how staff are to maintain eyes on R2, including contingency plans for when other resident needs may interupt the observation of R2 and will include a daily/ every shift schedule for which staff are responsible for the monitoring of R2. This POC is due by 11/7/24. Civil Penalties Applied.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465 · Plan of correction due date: Nov 8, 2024

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care ... The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self- administered medications as needed. This requirement was not met based on records and interviews which found care staff were not compliant with assisting R1 correctly with medications. This posed an immediate risk to R1.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: Staff found to have made the error have been removed from medication duties. Licensee agrees to retrain all mediation technicians on the 7 R's of med administration, implement procedures for med techs reviewing previous shift docuentation for all meds that they pass, and procedures for reporting/ responding medication errors/ inconsistencies to managers before the medication is administered, when applicable. Licensee will submit the plan for training and procedures to be reviewed to CCL by the POC date of 11/8/24

Type of visit: Case Management - Incident

On 9/17/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Generations Program Director (GPD), Charles Howard and Regional Clinical Specialist, Yvonne Williams . On 9/16/24, the department received an incident report for R1 leaving the facility unassisted on 9/7/24. The incident report stated that staff was alerted to the back gate alarm. Staff looked inside for R1 while others searched outside. R1 was found unharmed by caregivers, "10 minutes" from the facility. R1 refused to return to return to the community until encouraged by responding local law enforcement. LPA toured the facility with GPD to view where R1 was able to exit the property. Alarms from the exit door from the facility (near Rm 180 of the Lodge memory care) and the exit gate from the adjacent courtyard were operational. Though diagnosed with MCI at the time, R1 is in memory care. Interview with GPD found that R1 is known to have exit seeking behavior and to experience sundowning. R1 was staffed with a 1:1 caregiver from a staffing agency until shortly before the incident at approximately 6:30 PM. In addition to staff monitoring of residents, door alarms are monitored at the front desk for reception to alert caregivers to clear alarms. However, records reviewed found on 9/7/24, the front desk was only monitored until 5 PM. 3 caregivers were scheduled to work at the time. One of the 3 had just left on lunch break. Staff in the community were in the kitchen area opposite where R1 exited the building. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Sep 17, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: Sep 18, 2024

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and current appraisal health care needs as identified in his/her.. This requirement was not met based on reports and statements. This posed an immediate risk to R1's health and safety.the state’s words, verbatim · CDSS document, Sep 17, 2024

Plan of correction: Licensee will submit a plan for supervision, staffing and training plan for restidents in memory care by the POCdate of 9/18/24.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cassie Yang conducted unannounced case management visit on 09/13/2024. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES. LPA met with Generations Program Director with Regional Vice President on the phone and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective 09/13/2024 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.the state’s words, verbatim · CDSS document, Sep 13, 2024

Allegation investigated: Staff did not ensure that resident's bathroom was clean and sanitary.

On 8/30/24, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Director, Jessica Sanders. LPA conducted records review and interviews. LPA is unable to find and or meet the preponderance, per policy. LPA conducted visits on 6/18/24 and 8/30/24. On 6/18/24 R1 was unavailable for interview. R1 was interviewed today. The complaint was regarding an incident that occurred on 6/11/24 where R1 had a medical emergency and went to the hospital. At change of shift, while R1 was in the hospital, staff from the next shift was tasked with cleaning R1's bathroom. The bathroom was cleaned before R1 returned. In an interview with R1 on 8/30/24, R1 stated satisfaction with cleaning assistance provided for him and his room. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 30, 2024 · control 59-AS-20240612085306

Type of visit: Case Management - Other

On 8/30/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Director, Jessica Sanders. LPA was following up on incident reports submitted for the following resident issues. It was reported that on 8/11/24 and 8/18/24, R1 had falls which resulted in skin tears. LPA and Director reviewed the incidents and R1's current fall prevention strategies. Director reported R1 has had no further falls. Since 8/18/24, R1 has continued to adjust to their residency, has had medication adjustments and received physical therapy. LPA observed R1, who resides in memory care. R1 appears to have their current care needs met. LPA also followed up on a incident that occurred on 8/10/24 where it was reported that R2 entered the room of R3. R3 told R2 to leave and an altercation resulted with R2 hitting R3. Residents were separated and residents were assessed. Director reported that R2 resides in a different memory care unit that R3. R2 was accompanied by a med tech into the unit in which R3 resides. While the med tech was on the phone , R2 wandered away and entered R3's room. R2 in not a hazard to R3 at this time. LPA and Director discussed supervision communication for when the primary supervision is otherwise occupied. LPA observed these three residents in care. No health, safety or supervision issues are noted at this time. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 30, 2024

Type of visit: Case Management - Incident

On 6/12/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit, met with Jessica Sanders and explained the reason for the visit. On 6/6/24, the department received a SOC 341 submitted by the Director, Jessica Sanders. The report stated that on 6/4/24, medication tech S1 forced R1 to take medications at approximately 8 PM, after R1 had spit out R1's medications at the medication tech. S1 was assisted by caregivers S2 and S3 who restrained R1 while S1 put medications in R1's mouth and S1 covered R1's mouth so that R1 could not spit the medications out again. It is not known if resident spit out all medication in their entirety before additional medications were forced. S4 reported the incident to the Memory Care Director on 6/5/24. S5 reported the incident to the Director on 6/6/24. During this visit LPA interviewed the Director. Director stated S1's employment has been terminated. S2 and S3 are currently suspended pending further action. Staff training has been reviewed for staff present that shift regarded mandated reporting, resident right to refuse meds and no restraint policy with S1-S5.. Additional staff training to be done for all staff as part of the plan of correction (POC) LPA received copies of S1, S2 and S3 employee records, R1's physician's report and medication administrative record, staff schedules for 6/4/24, as well as staff statements, by S1-S5, collected in the course of the facility's investigation. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Jun 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5)(D) · Plan of correction due date: Jun 13, 2024

Incidental Medical and Dental Care (a)(5)(D) Assistance with self-administration does not include forcing a resident to take medication,... without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication. This requirement was not met on 6/4/24 when R1 was forced to take medications by two caregivers and a med tech. This posed an immedicate risk to the resident.the state’s words, verbatim · CDSS document, Jun 12, 2024

Plan of correction: Director has discussed mandated reporting, resident right to refuse meds and no restraint policy with S1-S5. Licensee will submit the training date for all staff regarding mandated reporting, resident right to refuse meds and no restraint policy. The training date will be submitted by 6/13/24. Following completion for the training, documentation of training and participants will be submitted to CCL.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87211(c) · Plan of correction due date: Jun 13, 2024

Reporting requirements- (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met by S1 or S2 who witnessed the incident of 6/4/24 and failed to report to police within 24 hours. This posed an immediate risk ro residents.the state’s words, verbatim · CDSS document, Jun 12, 2024

Plan of correction: Director has discussed mandated reporting, resident right to refuse meds and no restraint policy with S1-S5. Licensee will submit the training date for all staff regarding mandated reporting, resident right to refuse meds and no restraint policy. The training date will be submitted by 6/13/24. Following completion for the training, documentation of training and participants will be submitted to CCL.

Type of visit: Case Management - Other

On 5/16/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Jessica Sanders. LPA was following up on an incident involving R1 that occurred on 5/2/24. LPA conducted six (6) interviews of caregivers and med techs. LPA requested that licensee submit the following records regarding R1: Med tech notes regarding Hospice contact, Hospice care notes, Medication records, caregiver assignments document, R1's hospice care plan and prior records of a fall/ hospitalization and rehab for R1 shortly before initiation of Hospice services. Documents are requested by 5/23/24. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, May 16, 2024

Type of visit: Case Management - Incident

On 5/3/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Executive Director (ED), Jessica Sanders. On 4/24/24, the department received an incident report regarding an incident involving R1 that occurred on 4/20/24. The report stated that at approximately 3:55 on 4/20/24, R1 exited memory care and then was able to leave the property unassisted. After a search of the property was conducted, local police were notified. Police located R1 several blocks from the facility. R1 was returned unharmed to the facility. In interview with the ED,ED stated an internal investigation was unable to identify when and how R1 exited the facility. Tests of the facility's delayed egress alarms found them to be functioning properly. However, the exit doors were known to at times not close all the way. Staff were to regularly check that doors were closed. There were 2 caregivers on duty at the time with 12 residents. R1 was last seen at approximately 3:15 PM, having visited the Generations Program Director's office in memory care. R1's LIC 602 and appraisal identifies R1 as having dementia, exit seeking behavior and is unable to leave unassisted. An inspection of The Villa area where R1 resided, found an exit to the parking lot one door down from R1's room and a main exit from the lobby of The Villa. The lobby from The Villa is not staffed with a receptionist. Care staff greet and allow entry to visitors. As a result of this inspection, the following deficiencies were cited on 809-D. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, May 3, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: May 6, 2024

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and current appraisal health care needs as identified in his/her.. This requirement was not met based on reports and statements. This posed an immediate risk to R1's health and safety.the state’s words, verbatim · CDSS document, May 3, 2024

Plan of correction: Licensee has repaired doors to insure they fully close when exited. Licensee will submit records of staff training having been conducted as a result of this incident by the POC date of 5/6/24.

Type of visit: Required - 1 Year

On 02/21/2024 at 12:30 PM, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Executive Director (ED), Jessica Sanders, and explained the purpose of the visit. At 12:40 PM, LPA and ED toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, residents' bedrooms, bathrooms, kitchen, and courtyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. Toxic and cleaning supplies locked and is inaccessible to residents in care. Medications are locked and inaccessible to residents in care. The hot water temperature was measured in the bathroom at 113 degrees Fahrenheit. First aid kit was complete. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher was last serviced on 10/11/2023. Fire drill was last conducted on 01/18/2024. LPA observed required Licensing posters posted throughout the facility. At 1:00 PM, LPA reviewed a total of four (4) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for four (4) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of four (4) staff record. Staff has training were completed. No deficiencies being cited during today's inspection. Exit interview conducted with Memory Care Director, Jami Koopman, and report provided.the state’s words, verbatim · CDSS document, Feb 21, 2024

Type of visit: Case Management - Incident

On 02/21/2024, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Case Management- Incident to obtain information regarding an incident that occurred at the facility on 02/13/2024. LPA met with Executive Director (ED), Jessica Sanders, and explained the purpose of the visit. The Case Management visit is in response to an incident report that was submitted to CCLD. Incident report indicates, the facility were advised on 02/13/2024 from the pharmacy that a bubble pack of 30 oxycodone was delivered to the community on 02/07/2024. It was discovered that staff (S1) on the night shift signed off on the medication. The facility conducted an internal investigation of missing bubble pack. The facility notified Roseville Police Department. Resident's primary care physician was notified and responsible party. The facility conducted an in-service on receiving, logging, and storing narcotics on 02/17/2024 and 02/18/2024. LPA requested for in-service training for review. At this time, deficiencies are not being cited. An exit interview conducted with Memory Care Director, Jami Koopman, and report provided.the state’s words, verbatim · CDSS document, Feb 21, 2024

Allegation investigated: Staff who are not appropriately skilled professionals are administering medication to residents.

On 10/26/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver investigation finding. LPA met with Executive Director (ED), Nathan Condie, and explained the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews with facility staff and reviewed pertinent documentation relevant to the allegation listed above such as resident's (R1) physician’s report, emergency contact, appraisals, assessments, doctor's orders, hospice communication logs, medication list, control substance management policy, staff roster, and residents roster. Continue on page LIC9099-C. Unsubstantiated According to complainant, this community uses unlicensed professional staff such as medication technicians (MT) to administer Morphine on hospice resident. According to R1’s physician’s report, R1 is unable to administer own prescription medications, unable to administer own PRN medications, and unable to store own medications. R1 is unable to administer own injections, perform glucose testing, and oxygen. According to R1’s level of care assessment, R1 requires medication assistance up to 2 times a day. R1 is on hospice and currently does not require additional staff involvement. According to R1’s doctor’s orders, on 8/30/2022 Morphine 20 mg/mL liquid concentration (30 mL bottle) was prescribed to R1 per instruction administer 0.5 mL sublingually 2 times per day for pain or shortness of breath this is additional to PRN dose on 6/16/2023. On 8/4/2023, doctor’s orders indicated to discontinue Morphine 20 mg/mL oral concentration administer 0.5 mL 2 times per day. Begin Morphine 20 mg/mL oral concentration, administer 0.5 mL (10mg) sublingually 3 times per day for pain and shortness of breath, this is in addition to PRN dose. On 8/22/2023, Morphine is to be administered every 4 hours for pain and shortness of breath, this is in addition to PRN dose. The Department interviewed and received statements from a total of five (5) Med Techs. Med Techs denies administering Morphine to hospice residents. Interview statement received from Med Techs indicated the facility nurse who is a Licensed Vocational Nurse (LVN), hospice nurse, and residents' family members who are trained administer Morphine to residents who are not capable to assist themselves. Med Techs indicated, if a resident in care is capable of administering own medication without assistance Med Tech is to provide medication to resident and observe to ensure the safety of resident. On 9/18/2023, the Department received interview statement from R1's hospice nurse. Hospice nurse stated resident was prescribed Morphine and family members requested for R1 to be given additional doses for comfort. Hospice Nurse stated did not witness staff that are not skilled professional give morphine to R1. Hospice Nurse stated has worked at Meadow Oaks of Roseville for 6 years and has not witnessed unlicensed professional staff assisting R1 with Morphine. Hospice Nurse indicated Meadows Oaks of Roseville is good at contacting hospice to ensure that any medications such as narcotics are given to resident correctly with permission. Hospice Nurse indicated Meadow Oaks would always call hospice if they had any questions or concern or need recommendations/guidance. The Department finds the allegations to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are unsubstantiated. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 26, 2023 · control 59-AS-20230717124435

Type of visit: Case Management - Incident

On 10/26/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Case Management- Incident to obtain information regarding an incident that occurred at the facility on 09/25/2023. LPA met with Executive Director, Nathan Condie, and explained the purpose of the visit. The Case Management visit is in response to an incident report that was submitted to CCLD. Incident report indicates, a bubble pack of 30 Tramadol 50mg was not in the Narcotic Drawer on 09/10/2023. Resident Care Director, Kathryn Nevin, was immediately notified and searched the entire medication room. The facility conducted an internal investigation. Roseville Police Department were notified via telephone. Case number was provided. R1's doctor notified for refill of medication. R1's responsible party was notified. The facility provided in-service on 9/23/2023 and 9/24/2023 in regards to policy on narcotic count and general medication room policies and procedures. LPA requested for in-service training for review. At this time, deficiencies are not being cited. An exit interview conducted and report provided.the state’s words, verbatim · CDSS document, Oct 26, 2023