Primrose

Type of visit: Required - 1 Year

At 10:00am on 01/26/2026 Licensing Program Analyst (LPA) Jeffries arrived unannounced to conduct the annual facility inspection. LPA met with Administrator Dorothy Berger, announced who he is and the reason for the visit. LPA conducted facility annual for both facilities under this Licensee during this annual inspection. This facility has a fire clearance for a secured perimeter and has 12 resident room. 10 rooms are single resident occupancy, and rooms #3 and #12 are double resident occupancy. All resident rooms are properly furnished with bedding, storage, seating and lighting according to regulations There is one on suite bathroom for room #12 and there are 4 bathrooms that are located through out the facility that are community use bathrooms. All bathrooms have liquid soap and paper towels. LPA noted non-skid mats showers. There is a large great room that serves as a dining room, living room and activities room. LPA noted that there is a kitchen on the north side of the facility, however this facility's food service is maintained in the licensed facility next door.. The main food supply is located at the adjacent facility outside the facility gate, where LPA noted at least a 2 day supply of non perishable foods and at least a 7 day supply of perishable foods on hand for 28 (both facilities have a maximum number of 14 residents per facility) residents and staff. LPA noted that the facility has a medication room in the hallway near resident room #12. LPA noted that the first aide kit is located in the medication room. LPA noted the facility has overhead sprinkler system with smoke detection that was last tested and certified by Santa Barbara County Fire department on 04/07/2025. LPA noted three fire extinguishers throughout the facility that were charged in the green and currently tagged as serviced. LPA noted that all passage ways were free and clear of debit and obstacles. LPA noted that the fire clearance authorized locked gates on the perimeter gates. LPA conducted a sample review of staff and resident files. LPA noted and reviewed facilities current emergency disaster plan and infection control plan, and liability insurance LPA conducted a full review of the annual care tools and found no citations or deficiencies. This annual inspection did not revel any citations or deficiencies. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Jan 26, 2026

Allegation investigated: Resident was sexually abused in facility.

At 9:00am on 10/23/2025, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to issue final findings to the allegations to this complaint. LPA met with facility Administrator, Dorthey Berger, announced who he is and the reason for the visit was to issue final finding to the allegation to this complaint. LPA also conductd additioanl interviews. On 09/16/2024, the Department received a complaint regarding an allegation of Sexual Abuse. The complaint alleged Resident 1 (R1) while in care suffered, multiple dark-purple bruises to the perineal area, suggesting sexual abuse while in care. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Jorge Rojas. On 09/17/2025, from 7:25am to 9:56am, LPA Jeffries arrived to the facility unannounced to conduct a health and welfare visit based on a personal rights allegation to this complaint. LPA met with Administrator, Dorthy Berger, announced who he is and the reason for the visit. LPA requested documentation. Administrator and LPA conducted a facility physical tour. CONTINUED on LIC9099-C Unsubstantiated LPA observed residents in care, 6 of 11 residents in the common room, 3 of 11 residents were in their bedrooms and two residents not currently in the facility. At time of visit Resident 1 (R1) was in the hospital. LPA needed more time to conduct investigation, conduct interviews, review and request documentation, and will return at a later time to issue final findings. On 09/18/2025, Investigator Rojas requested medical records for R1 from Marian Regional Medical Center. A review of medical records on 09/22/2025 shows that on 09/09/2025, R1 was hospitalized due to a fall and a nurse noted bruising over the upper bony area of the vagina, and a laceration with oozing was also noted. However, 50 minutes later, another nurse corrected the statement and removed “bruising to top of boney area of vagina.” On 09/14/2025, notes state a nurse observed dark purple bruising on the clitoral hood, vaginal canal, and bilaterial labia majora. On 09/14/2025, R1 tested negative to any blood borne diseases. On 09/15/2025 R1 was seen by a physician, who noted no signs of excoriation or bruising on the exam around the genitalia area. On 09/15/2025, another physician noted that R1 reported generalized aches but could not specify the pain’s location or nature. Medical records indicate R1’s family member (F1) observed increased confusion and attributed the vaginal bruising to a fall three of four weeks ago, expressing doubt of elder abuse. Another family member (F2) agreed, stating they would be surprised if abuse occurred at the facility, believed the bruising resulted from the fall on 09/09/2025, denied any concerns about abuse or neglect, and believes R1 would have spoken up if mistreated. On 10/09/2025, Investigator Rojas contacted facility Administrator, Dorthy Burger who stated R1 was no longer residing at the facility. The facility had experienced a COVID-19 outbreak when R1 was ready to be discharged from the hospital, so R1’s family chose to relocate them to a different facility. On 10/09/2025, Investigator Rojas contacted F2 by phone, but F2 declined to provide requested information to the investigator. The investigator determined what facility R1 was at and contact the administrator at the new facility on 10/10/2025. The administrator stated R1 arrived at the facility on hospice due to deteriorating health, was no longer able to communicate, and was showing signs of being near end of life per hospice staff; therefore R1 was not interviewed. CONTINUED on LIC9099-C On 10/23/2025, LPA Jeffries conducted staff interviews of 3 staff (S1, S2, and S3) who all stated that, they feel they feel confident in the facility direct care training and confident to meet the needs of the residents, all stated they have confidence in all the staff, and have no issues or concerns with staff care giving. On 10/23/2025, LPA Jeffries conducted interviews of 4 of 10 residents (R2, R3, R4, and R5) all Residents stated they feel staff is well trained, feel safe at facility and have no issues with staff. LPA not able to interview remaining 5 residents due to cognitive ability levels. As a result of R1 having conflicting medical records that initially discussed bruising, then were deleted, and the physician’s exam concluded “no excoriations or genital bruising” were found. Based on medical records and interviews conducted, there is insufficient evidence to support that allegation of “Resident was sexually abused in facility.” Therefore the allegation is unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 29-AS-20250916155953

Type of visit: Required - 1 Year

At 8:00am on 03/13/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to conduct the annual facility inspection. LPA met with Administrator Dorothy Berger, announced who he is and the reason for the visit. This facility has a fire clearance for a secured perimeter and has 12 resident room. 10 rooms are single resident occupancy, and rooms #3 and #12 are double resident occupancy. All resident rooms are properly furnished with bedding, storage, seating and lighting according to regulations There is one on suite bathroom for room #12 and there are 4 bathrooms that are located through out the facility that are community use bathrooms. All bathrooms have liquid soap and paper towels. LPA noted non-skid mats showers. There is a large great room that serves as a dining room, living room and activities room. LPA noted that there is a kitchen on the north side of the facility, however this facility's food service is maintained by the same owners and administrators adjacent licensed facilities kitchen. The main food supply is located at the adjacent facility where LPA noted at least a 2 day supply of non perishable foods and at least a 7 day supply of perishable foods on hand for 28 (both facilities have a maximum number of 14 residents per facility) residents and staff. LPA noted that the facility has a medication room in the hallway near resident room #12. LPA noted that the first aide kit is located in the medication room. LPA noted the facility has overhead sprinkler system with smoke detection that was last tested and certified by Alpha Fire on 10/24/2024. LPA noted wire carbon monoxide detector with a green light throughout the facility. LPA noted three fire extinguishers throughout the facility that were charged in the green and currently tagged as serviced. LPA noted that all passage ways were free and clear of debit and obstacles. LPA noted that the fire clearance authorized locked gates on the perimeter gates. LPA conducted a sample review of staff and resident files. LPA noted that all staff are current on training with 1st Aide and CPR training up to date. LPA conducted a sample medication audit and did not discover any deficiencies. LPA noted and reviewed facilities current emergency disaster plan and infection control plan, LPA conducted a full review of the annual care tools and found no citations or deficiencies. This annual inspection did not revel any citations or deficiencies. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Mar 13, 2025

Allegation investigated: Staff are not providing resident's authorized representative with copies of resident's records

This is an amended report On 10/09/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced complaint investigation visit to the facility above to deliver final findings for the above allegations. During today’s visit, LPA Phillips met with Administrator Dorothy Berger and Licensee Margie Halsell, and explained the reason for the visit. On the allegation: Staff are not providing resident's authorized representative with copies of resident's records. It is alleged that when Resident #1 (R1) was discharged from the facility above on 09/30/2024, their Representative asked the facility for a copy of R1’s Weight Log but did not receive an updated document with entries for all weeks R1 was in care. The allegation states that if the facility is logging the information, then it should be in R1’s file and their Representative should get copies. According to the allegation, the California Code of Regulations (CCR) Title 22 §87468.2(a)19 states that the Representative of R1 should have copies of all records including an updated weight log. Continued on 9099-C Substantiated This is an amended report. On 9/30/2024, R1 was discharged from the facility above by their representative/responsible party. Prior to the date of discharge, R1’s representative requested copies of R1’s facility file documentation. On 09/18/2024, R1’s representative requested and received facility documentation including a Weekly Client Weight Record for the weeks of 06/26/24-09/18/2024 with documented entries for all weeks R1 was in care at the facility except the last week prior to discharge. On 10/04/2024, the Representative of R1 showed LPA evidence of having obtained the Weekly Client Weight Record with documented entries through the week of 09/18/2024. The allegation stems from the fact that the document obtained by R1’s representative is missing one (1) entry in the weekly client weight record for the last week R1 was in care at the facility. R1’s representative believes they are entitled to an updated weekly client weight record with all weeks R1 was in care at the facility documented. The facility provided R1's representative their weight record from admission to discharge except for the last week the resident was in care (documented weeks of 6/26/2024-9/18/2024). At the time of the request on 09/18/2024, this weight log was current. R1’s representative requested and received R1’s facility file information again on 09/29/2024. At the time of this second request, the Weekly Client Weight Record was still current. On 10/02/2024, after R1 had been discharged from the facility, their representative sent a telephone text message to the facility contact number requesting an updated Weekly Client Weight Record document for R1 with their recorded weight taken on the date of discharge (09/30/2024). According to staff interviews by LPA, this text message was not read until up to four (4) days later since R1 no longer resided at the facility, and as communications, attitude, and behavior by R1’s representative had interfered with and undermined the Staff at the facility. Administrator stated when they read the text message, they thought it was referring to documents that were already provided to the representative. Administrator did not understand the representative wanted an additional updated document until LPA arrived at the facility on the complaint. Documentation of a Care Meeting between the facility and R1’s representative on 07/30/2024 stated that Staff felt harassed while doing their job due to rude comments, forceful demeaning tones, aggressive language, and contradictory demands by R1’s representative on a regular basis. The facility is not mandated by Community Care Licensing Division (CCLD) to provide documentation of the resident’s weight record unless there is any unusual weight gain or unusual weight loss. Resident weight logs/records are not technically required to be maintained in a resident’s file in general unless there is any unusual weight gain or unusual weight loss. The CCLD regulations only state that when changes such as unusual weight gains or losses are observed, the facility shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's representatives. Contd. 9099-C This is an amended report. LPA found no evidence that there was an agreement to pay more for weekly weight records of R1 by the facility and the Representative of R1. Through record review of R1’s documented facility file, LPA observed that weight gains/losses by R1 have been documented by the facility in R1’s file which was provided to R1's representative upon request on 09/18/2024 and 09/29/2024. R1’s Physician’s Report for Residential Care Facilities for The Elderly (RCFE), signed and dated 02/24/2024, indicates R1 needs a low sodium diet with no milk. The Pre-Placement Appraisal Information for R1, signed/dated by R1’s Representative on 06/05/2024 and the Licensee on 06/10/2024, indicates R1 needs service of a special diet/observation of food intake. This consists of a low sodium and low starch diet. Admission considerations for R1 state that R1 has had recent weight gain/loss caused by fluid retention prior to admission to the facility. Progress notes from a 09/05/2024 primary care physician (PCP) visit by R1 indicate treatment includes low sodium/low cholesterol/low fat diet and exercise. The PCP progress notes from 09/05/2024 also document that R1 has denied any vomiting or weight loss. R1’s current weight was recorded and reviewed by their PCP on 08/05/2024 and 09/05/2024 in Medicare wellness visits with no concerns identified. In a documented statement by R1 during a PCP visit on 09/05/2024, they stated they have no lack of food and no concerns about food. A review of patient symptoms for R1 by their PCP on 09/05/2024 indicated a negative for unintentional weight loss. The complaint allegation states that California Code of Regulations (CCR) Title 22 §87468.2(a)19 means that the Representative of R1 should be entitled to an updated Weekly Weight Record for R1. This regulation states that residents in privately operated residential care facilities for the elderly shall have the personal rights to have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days. This regulation applies to records documented by the facility and kept in the resident file. The Representative of R1 requested and received the Weekly Client Weight Record document for R1 provided by the facility on 09/18/2024 and 09/29/2024, which were current at the time they were provided. However, R1’s representative again requested a current updated Weekly Client Weight Record for R1 on 10/02/2024 which was not provided by the facility until a complaint investigation visit by LPA on 10/09/2024. On 10/09/2024 during this complaint investigation visit by LPA, the facility provided documentation of the weight of R1 on 09/30/2024 for the Weekly Client Weight Record. LPA observed a facility staff member send this updated document to the Representative of R1. Continued on 9099-C This is an amended report. R1's representative had previously requested and received a current Weekly Client Weight Record from the facility on 09/18/2024 and 09/29/2024. There is documented evidence of R1’s representative requesting the Weekly Client Weight Record for R1 on 09/18/2024 and 09/29/2024 through email communications with the facility, prior to the weighing of R1 on 09/30/2024. Copies of the current Weekly Client Weight Record were provided to R1’s representative at the time of the requests. There is additional evidence that the representative of R1 requested an updated Weekly Client Weight Record to show the weight of R1 on 09/30/2024 through a text message to the facility on 10/02/2024. This updated document was not provided to R1’s representative until 10/09/2024 through a complaint visit by the LPA. Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated. Exit interview conducted. Technical Violation issued. Copy of report provided to the facility.the state’s words, verbatim · CDSS document, Oct 9, 2024 · control 29-AS-20241007145012

Allegation investigated: Facility charging resident for services not provided in admission agreement addendum

On 10/03/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint investigation visit to the facility above to deliver final findings for the above allegations. During today’s visit, LPA Phillips met with Medical Technician (MedTech) Yuribeth Reyes as the Administrator was unavailable, and explained the reason for the visit. On the allegation: Facility charging resident for services not provided in admission agreement addendum. Due to Resident #1 (R1) requiring lengthy time bathing, grooming, and dressing, along with extra trips to the bathroom, an addendum to R1’s admission agreement was signed and dated for an increase in fee for R1 due to an extra 60 minutes of toileting, an extra 85 minutes for personal care, and bathing with stand by assist. It is alleged that after the signing of the addendum, the facility is leaving R1 unsupervised during activities of daily living, not following fall risk guidelines. The allegation would like the total increased amount of money charged to R1 from the addendum be returned to R1 and their representative(s) as the facility is not allegedly providing the services charged in the addendum. Continued on 9099-C Unsubstantiated On 09/26/2024, LPA conducted a complaint investigation visit to the facility above. During this visit, LPA interviewed credible witnesses to the allegation in the complaint. LPA also requested and received relevant documentation pertinent to the allegation for record review. LPA reviewed R1’s Physicians Report for Residential Care Facilities for the Elderly (RCFE). The Physicians Report for R1, dated 02/24/2024, stated that R1 has difficulty walking and weakness of the musculoskeletal system. R1 is listed as having mild cognitive impairment, with cognitive abilities between normal aging and dementia. R1 has a mental condition listed by the physician as being slightly confused/disoriented at times. The physician listed R1’s capacity for self-care as being unable to bathe self without assistance, unable to dress/groom self without assistance, and needing assistance with toileting needs. The ambulatory status of R1 is non-ambulatory based on physical condition and mental condition. LPA received the documented facility Preplacement Appraisal information for R1 dated 06/10/2024. The Preplacement Appraisal information for R1 states that R1 has physical limitations including needing a walker for assistance due to a history of fall and foot injury. R1 was deemed a fall risk by the facility. R1’s functional capabilities were listed as requiring personal help for mobility and needing a walker and/or wheelchair which R1 needed assistance entering/exiting. R1 has documented services needed from the facility with transferring in and out of bed and dressing, help with bathing, hair care, and personal hygiene. R1 is documented to need facility staff to assist with toileting, including assistance equipment and assistance of another person. The admission agreement considerations of R1, documented by the facility on 06/11/2024, indicate that R1 had a sprained left foot with drop foot and left leg nerve damage due to a recent fall. Both the Preplacement Appraisal and Admission Agreement of R1 indicate that R1 dislikes being perceived to be rushed while conducting Activities of Daily Living (ADL) including bathing, grooming, and toileting. LPA conducted review of facility records that indicated approximately two (2) months after R1 was admitted to the facility, an addendum was signed and dated between the facility and R1’s Responsible Party for an increase in fee for R1 due to an extra 60 minutes of toileting, an extra 85 minutes for personal care, and bathing with stand by assist. Documented communication between the facility and representatives of R1 on 07/30/2024 and 07/31/2024 indicated that representatives for R1 stated that R1 was independent and can bathe alone until needing to be taken back to their room. R1’s representatives also stated that R1 should be left alone when toileting aside from transportation and left alone when grooming and putting on their own footwear. The Responsible Party of R1 requested the facility leave R1 unsupervised for periods of time while R1 is bathing, grooming, dressing, and toileting with facility caregivers checking in on R1 sporadically instead of constant stand by supervision of R1. Continued on 9099-C The facility communicated to the representatives of R1 that R1 required an additional 1-2 hours of shower time, and an additional 85-90 minutes of personal care. The facility indicated that the physical care of R1 takes an inordinate amount of time, which prevents staff from providing the same care to other residents. The facility also stated to the representatives of R1 that they are interfering with the ability of the facility to provide care to all residents with the frequent and sometimes conflicting requests for R1. On 09/13/2024, the facility communicated with representative(s) of R1 that R1 warrants a one-to-one caregiver at the expense of the Responsible party due to R1’s care needs, but this has not been provided at the time of this report. The facility stated that it is extremely difficult to stay with R1 for hours at a time as there is a limited number of staff and up to 13 other residents in the facility. The facility communicated that security camera footage shows the longest timespan between staff checks on R1 overall was 9 minutes in the facility, but that during ADLs R1 had stand by assistance from staff. Documented facility Narrative Charting from July 2024 and August 2024 indicates that R1 is on 15-minute monitoring by facility staff overnight and that R1 would use a bell alert system from their room to notify staff they needed to use the restroom 1-2 times overnight. Narrative charting from the facility also documented procedures for bathing R1 including transferring R1 from their wheelchair into a shower chair, turning on the water, and handing R1 the hygiene products. Narrative charting indicates that facility staff would stand by as R1 would wash/clean themselves. Staff would turn off the water for R1, assist with providing R1 a towel to dry themselves, and assist R1 with putting on clothing and footwear. Facility narrative charting from 07/16/2024 indicated that R1 spent 1 hour in the shower with the Responsible Party of R1 observing the entire time. Facility staff conducted stand by assist supervising R1 bathe. On 07/22/2024, facility narrative charting indicated that facility staff, a physical therapist for R1, and R1’s Responsible Party all observed R1 bathing/showering as staff were told that R1 can wash themselves and dress themselves independently, but with visual supervision. This bathing/shower lasted approximately 50 minutes. On 07/31/2024, narrative charting indicated that the responsible party of R1 stated to staff that R1 cannot be left alone during ADLs. On 08/05/2024, narrative charting indicated that R1 was observed by their responsible party during the supervised and assisted bathing/showering by facility staff from approximately 7:20am-8:15am. On 08/06/2024, narrative charting by the facility indicated that R1 requested to go to the bathroom at 6:30am and was left alone for a few minutes after transferring R1 as they were seated on the toilet, but they were then supervised by staff. The narrative charting indicates after toileting, R1 was able to conduct their personal care independently with stand-by supervision. At 7:45am, R1 was returned to their bedroom until 8:15am, with staff going back and forth checking on R1 frequently. Contd. 9099-C Staff interviewed by LPA stated that when speaking with the Responsible Party of R1, they indicated that some residents can be left alone when bathing/grooming, but certain residents including R1 needed stand by assistance from staff as they were fall risks. According to staff interviewed by LPA, the Responsible Party for R1 visited the facility and stated to staff that R1 cannot be left alone during ADLs such as bathing/grooming. Staff interviewed by LPA stated that at certain times when the Responsible Party of R1 would visit the facility, staff were told by the Responsible Party not to assist R1 with drying themselves after bathing/grooming as staff were told by the responsible party that R1 could do that themselves. Staff interviewed by LPA indicated that providing R1 with stand-by assistance means that R1 is provided with a type of support where staff remain close to R1 to help prevent falls or injuries. Staff stated to LPA that stand-by assist is not touching R1 but being there to help if needed. Staff stated to LPA they do assist R1 with ADLs, but stand-by assistance is for R1 who can function on their own but may not be safe without someone nearby because of a risk of falling. Interviews by LPA with all credible witnesses indicate that stand-by assistance is conducted by facility caregivers during ADLs, when a resident can perform the actual ADL on their own, but may need a little extra help, for example, maintaining their balance or remembering the order things are done in. The stand-by assistance is maintaining proximity and supervision of the resident, not physically assisting the resident with bathing, grooming, and toileting. It is not required in the Community Care Licensing Department (CCLD) regulations that a facility document the timeline of extra care minutes on narrative charting. However, the facility did provide narrative charting including the amount of time and procedures regarding R1’s bathing, grooming, and toileting. A representative of R1 and a therapist for R1 physically observed staff assisting with R1’s ADLs and providing stand by assistance to R1 on several occasions in July 2024 and August 2024. There is also adequate documentation that R1 is a fall risk including R1’s Physician Report, R1’s Preplacement Appraisal, and R1’s Admission Agreement. The facility provided documentation on the necessity of the increase in rate for R1 due to additional time needed for ADLs in the admission agreement addendum. The facility can charge more for providing more assistance, within Licensing regulations. All staff interviewed by LPA indicated that they had an appropriate understanding of the stand-by assistance procedure required for a resident who was a fall risk in the facility. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. Exit interview conducted. Copy of this report provided.the state’s words, verbatim · CDSS document, Oct 3, 2024 · control 29-AS-20240920132523

Allegation investigated: Facility staff mismanged resident's medication Facility staff did not appropriately communicate a change of condition

On 09/26/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint investigation visit to the facility above to deliver final findings for the above allegations. During today’s visit, LPA Phillips met with Administrator Dorothy Berger and explained the reason for the visit. On the allegation: Facility Staff mismanaged resident’s medication. It is alleged that there are multiple incidents in which Resident #1 (R1) had medication errors caused by facility staff. These incidents allegedly occurred on 08/19/2024, 08/20/2024, 09/16/2024, and 09/20/2024. The allegation states the medication errors by staff consisted of medication being given at incorrect doses to R1 at the wrong time of day, staff losing portions of medication tablets that were supposed to be dispensed to R1, and staff not checking that R1’s responsible party had been given the correct medications prior to R1 having an outing from the facility. Continued on 9099-C Substantiated On 08/27/2024, the Department received a self-reported Unusual Incident/Injury Report (UIR) regarding Resident #1 (R1) alleging that on 08/19/2024, the administrator of the facility accidentally placed the 8:00am medication for R1 in the 12:00pm dispensing cup, and the 12:00pm medication for R1 in the 8:00am dispensing cup. Facility staff noticed the mistake during the passing of medications at 11:45am and called the primary care physician of R1 but received no answer. Staff additionally called the responsible party for R1. The vitals of R1 were checked and they were placed on 15-minute charting. The UIR stated R1 was orientated, no altered state, no signs of distress, no complaints of dizziness, discomfort, or pain. On 08/28/2024, the Department received a self-reported UIR regarding R1 alleging that on 08/20/2024, facility staff poured/administered medication for R1 out of a bubble pack and a portion of the medication had broken apart while being popped out of the pack. On 09/10/2024, LPA conducted an initial complaint investigation visit to the facility. LPA requested and received relevant documentation from the facility pertinent to the allegations and interviewed Staff about the incidents involving R1. LPA received Addendums to both the 08/19/2024 and 08/20/2024 UIRs regarding medication errors for R1. The addendums provided additional details of the errors by the administrator on 08/19/2024, and the facility MedTech on 08/20/2024. Staff interviewed by LPA stated that on 08/20/2024, they were distracted by another resident at the door to the medication room when they popped the pill out of the bubble pack. When staff popped the individual pill into the cup meant for dispensing medication to R1, they did not realize that all of the pill had not been popped. Staff stated there had been a call to the facility by responsible party of R1 to state not all of the pill had been dispensed. Staff then checked the medication room and found the missing piece of the pill that had broken off when popped out of the bubble pack. Staff stated R1 was getting picked up early that day (8/20/2024) so they communicated with other staff and gave R1's medications to R1' responsible party for release while R1 was out of the facility. The medications for release were placed in a sealed envelope, the envelope was labeled by Staff and R1's responsible party. On 09/24/2024, the Department received a self-reported Unusual Incident/Injury Report (UIR) regarding resident #1 (R1) alleging that they had a medication error on 09/16/2024, caused by facility staff. The UIR noted that on 09/16/2024, at approximately 6:30am, facility Staff poured the 8am, 12pm, and 2pm medication for R1. Facility staff stated that the 12pm medication for R1 was pre-cut from 09/15/2024, as R1 is prescribed 5mg per dose and the medication received from the pharmacy arrives to the facility as a 10mg pill. Staff stated that the 12pm medication may not have been precisely divided in half as there appeared to be bits of broken/crumbled pill. Continued on 9099-C To prevent this from occurring again, the facility requested and received 5mg size medication pills from the pharmacy that no longer need to be cut at the facility for R1. On 09/24/2024, the Department received a self-reported Unusual Incident/Injury Report (UIR) regarding resident #1 (R1) alleging that they had a medication error on 09/21/2024, caused by facility staff. The UIR noted that on 09/21/2024, facility staff did not give R1 their 12pm medication as staff did not see the medication in the Medication Administration Record (MAR). Staff did see the 12pm medication for R1 in a dispensing cup in the facility medication room. However, staff was confused and thought it might be prior medication from a previous dispensing to R1. Staff did not realize this mistake until the next day on 09/22/2024, and the blood pressure of R1 was not checked at 12pm for R1. Staff was counseled on safe medication preparation and medication training was conducted. The facility/Licensee policies and procedures on resident medications were reviewed. Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated. On the allegation: Facility staff did not appropriately communicate a change of condition. It is alleged the blood pressure of R1 at 11:30am on 08/19/2024 constituted an overdose as blood pressure medication was the missed medication for R1 in the 08/19/2024 missed medication incident. It is alleged that the facility did not appropriately report a change in condition of R1 to their Primary Care Physician at the time of the missed medication incident on 08/19/2024. The allegation states that in the UIR provided to the Department, the facility stated that they had spoken to the Reporting Party (RP) prior to providing R1 an electrolyte drink. However, allegedly RP was not spoken with by the facility prior to providing R1 with the electrolyte drink. Based on staff interviews and record review conducted by LPA on 09/10/2024, when the medication error regarding R1 on 08/19/2024 was discovered by the facility, staff attempted to communicate a change of condition in R1 to their Primary Care Physician (PCP). However, the PCP for R1 was at lunch and unable to speak to facility at the time of the medication error. The facility called the PCP by telephone but did not leave a voice mail message at the Doctor's office so there were no calls documented and the doctor's office did not know anything was wrong. On 09/10/2024, LPA received self-reported Addendum UIRs for the 08/19/2024 and 08/20/2024 medication incidents involving R1. The 08/19/2024 addendum included information that at 1:26pm, facility staff gave R1 an electrolyte drink prior to speaking with the responsible party of R1. However, at 1:36pm, the administrator spoke with the responsible party of R1 who advised the administrator to give R1 an electrolyte drink. Continued on 9099-C At the time of the phone call at 1:36pm, the facility administrator was not aware that facility staff had already given R1 an electrolyte drink at 1:26pm. Regarding the 08/19/2024 incident involving the blood pressure medication of R1, the facility attempted to contact the responsible party of R1 by telephone within half an hour of the facility realizing the medication mistake but received no answer. The facility was able to speak with the responsible party of R1 within an hour and a half of the realization of the medication mistake and communicated what had happened. A family member of R1 physically visited the facility two and a half hours after the realization of the medication incident and stayed at the facility for two hours. R1 was reported to be oriented, no altered state, no signs of distress, no complaints of dizziness, discomfort, or pain. The facility documented all significant occurrences that may result in changes in the resident’s physical, mental and/or functional capabilities and immediately attempted to report these changes to the resident’s physician and authorized representative. Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated. Exit interview conducted. Copy of this report provided to the facility.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 29-AS-20240903160815

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 27, 2024

Addt'l Personal Rights Residents...(a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, services that meet individual needs…delivered by staff sufficient in numbers, qualifications, competency… This requirement is not met based on interviews and records review, licensee did not comply with the section cited above when Staff caused multiple medication errors for Resident #1, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Licensee will provide all Staff with a training on Resident Personal Rights and medication training to assist residents with medical attention. Licensee has changed medication with pharmacy and trained Staff in policies/procedures.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Oct 23, 2024

Personal Rights...(a) Residents in RCFE shall have all of the following personal rights: (8) To have...representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs This requirement is not met as evidenced by: Based on interviews and records review, licensee did not comply with section cited above by failing to report an incident and change of condition to a resident’s physician, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Licensee will provide all Staff with Personal Rights training regarding residents in care at the facility. Training will include personal rights training for all deficiencies cited, including the informing of responsible parties when a resident has a change in condition.

Type of visit: Required - 1 Year

On 03/12/2024, Licensing Program Analyst (LPA) Brian Phillips arrived unannounced for an unscheduled visit to conduct a required Annual site inspection visit at the facility above. When the LPA arrived, they were greeted by Administrator Dorothy Berger, Licensee Margie Halsell, and Business Manager Susie Halsell and informed them of the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This is a Residential Care Facility for the Elderly (RCFE), with an approved fire clearance capacity of Fourteen (14) residents. The facility is approved for Thirteen (13) non-ambulatory residents, of which Three (3) may be bedridden, with an age range of residents sixty (60) years of age and older. The facility has an approved Hospice Waiver for Seven (7) residents. The physical plant of the facility consists of two connected buildings with resident bedrooms, restrooms, shower areas, a beauty salon, Staff offices, laundry room area, storage room areas, and Staff office rooms/areas. The facility contains an outside area for residents to utilize for outdoor activities/outdoor visitations and an outdoor patio area with furniture and shade. The exterior of the facility has an approved secured perimeter which consists of a metal fence around the entire facility with locked gates. The gates are locked through a combination of electronic punch numbered locks as well as traditional key locks. KITCHEN: The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in a locked drawer inaccessible to residents. Kitchen appliances were in operable condition and looked clean/in good repair. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which would last over a week (7 days). Additional perishable food items were maintained in a storage area in the garage of the facility as well as an extra refrigerator and extra freezer located in the garage of the facility. The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation between 105-120 degrees Fahrenheit. Items that could constitute a danger to residents are kept inaccessible to residents in the kitchen area. The kitchen was clean and sanitary, with covered trashcans and operating ventilation systems. Continued on 809-C No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. The freezer and refrigerator were both in the appropriate temperate Fahrenheit. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. COMMON AREAS: At the time of the visit, the common areas of the facility were observed to be appropriately furnished, with all furniture in good condition. There is a fireplace in the facility, located in the dining area/living room that is covered an inaccessible to residents. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector(s) were operational at the time of the visit. The facility has multiple fire extinguishers that were fully charged and serviced annually. This is a single-story facility with a main dining room/living room area, kitchen area, salon, laundry room, 12 resident bedrooms, 4 restrooms, a locked centrally stored medication containment area, extra storage areas for additional perishable food, cupboards in the hallways of the facility containing extra linen/bedsheets/pillows, and storage areas for resident personal hygiene equipment constituting the interior areas of the facility. The LPA observed required postings throughout the common spaces including Resident Personal Rights and Contact information for Ombudsman as well as Licensing. There are activity supplies and equipment, including activity materials for the residents such as television, puzzles, games, etc. All window screens were in good repair. There is appropriate lighting in the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all inclines are well-lit with no stairwells/stairs for resident use. The laundry area for the facility is located in a locked room area off of the interior hallway of the facility that is inaccessible to residents. There is a main entrance walkway into the facility and an administrative entrance area for visitors. The facility has electronic auditory systems on all doors that can exit the interior of the facility, with a loud noise when a door exiting the facility is opened. The kitchen, living room, and dining area are neat and clean. The facility maintains a comfortable temperature. Hallways, bedroom doors, and walls are in good repair. Storage areas within the interior of the facility contain extra perishable food, hygiene products, PPE material, and cleaning products. OUTSIDE/LAUNDRY/MISCELLANEOUS: The exterior of the facility has an approved secured perimeter which consists of a metal fence around the entire facility with locked gates. The gates are locked through a combination of electronic punch numbered locks as well as traditional key locks. Inside of the locked perimeter is the outdoor/outside activity area for residents with a patio, furniture, shade, benches, and grassy areas. Continued on 809-C The recycling bin, green waste bin, and trash bins are standard bins with flip lids. The facility has an outdoor activity area that is provided with a shaded area and furnished for outdoor use. There are no bodies of water noted on the facility property. However, the neighboring facility has a small water collection reservoir inaccessible to residents as it is outside of the locked perimeter fence. The designated laundry area is where cleaning products are stored, which are kept locked and inaccessible to residents. The laundry room is accessible through the interior hallway of the facility as a specific area which has all hazardous items locked with key locks. Staff members are the only individuals allowed to do laundry and the entire room is kept locked at all times. There was emergency food and water in a storage area pantry next to the kitchen and in the extra perishable food storage area which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to residents are kept in areas inaccessible to residents. There is a first aid kit that includes sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. The vehicles used to transport residents are in safe operating condition with appropriate insurance information. LPA did not observe any noticeable outdoor hazards in areas accessible to residents. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are twelve (12) designated resident rooms in the facility with either 1 resident per bedroom or shared bedrooms with 2 residents per bedroom. The bedrooms have storage areas for clean linens, towels, pillows, etc. Each resident’s bedroom has a single bed, nightstand, and lights/nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assistive device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are four (4) resident bathrooms in the facility. All restrooms inspected had assistive equipment for residents including grab bars and/or non-skid surfaces. The restrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations between 105-120 degrees Fahrenheit. Nightlights are installed in the hallways outside of the resident restrooms. The facility maintains both communal restrooms for residents in the hallways of the facility, as well as a personal restroom for residents in a shared bedroom. Continued on 809-C RECORDS: The facility keeps confidential storage of both resident and Staff member records on-site at the facility. Staff member records were reviewed for, but not limited to Health Screening Report/Tuberculosis (TB) Clearance for facility personnel, Personnel Record (employment application), verification of age over 18 years old, education, and experience, approved Certification for the Administrator, verification of first aid training, Criminal Record Statement, Criminal Record Clearance/Exemption, Verification of Staff training, Employee Rights, and Abuse Reporting Requirements. All staff members’ personnel records reviewed by LPA had the appropriate documentation. The administrator of the facility has a Residential Care Facility for the Elderly (RCFE) Administrator Certificate that is currently in the Renewal Pending process. The Administrator Effective date is 9/9/2021 and Expired 9/8/2023. However, the RCFE Renewal process began on 7/27/2023 with Renewal Application Received 7/31/2023 and Payment received 8/1/2023. Resident records were reviewed for, but not limited to Pre-Admission/Placement appraisals, Resident Appraisals, Appraisal Needs and Services Plan (ANS), Physicians’ Report for RCFE, Identification and Emergency Information, Current Admission Agreement with signatures, Personal Rights for Residents, Record of Residents safeguarded cash resources, Record of Resident personal property/valuables, Physician Orders for Life Sustaining Treatment (POLST), Responsible Person or Conservator of Resident, Self-management of medications if applicable, Medication Orders, and Medication Logs. The facility also keeps records of resident vital signs and a resident weight record for all resident files reviewed. All resident records reviewed by the LPA had the appropriate documentation with no missing or incomplete information. MEDICATIONS: The facility maintains a locked centralized storage area for resident medications. Centrally Stored Medications are in a locked room that has a combination electronic lock on the door, which remains locked at all times, inaccessible/locked to residents. The locked room with the centrally stored medications is off of the dining room/living room area of the facility, at the end of the hallway from resident rooms and storage areas. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record, The Medication Administration Record, and the record of Controlled Medications. LPA audited the medications for residents and noticed no irregularities or issues concerning the dispensing of medications or the logging of medications. The medications in the facility were labeled appropriately with no additional or prohibited markings by the facility. INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening and a sanitation station. The staff members will keep up signs that promote good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. Continued on 809-C The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. FACILITY DOCUMENTATION: There are required postings throughout the facility, including emergency exit plans with necessary telephone numbers. The facility keeps posted copies of facility documentation such as the RCFE License Certificate, LIC 500 Personnel Report, Documentation of Facility Waivers, Plan of Operation, Emergency Disaster Plan for Residential Care Facilities for the Elderly (RCFE), Facility Infection Control Plan/Mitigation Plan, Certificate of Liability Insurance, Valid Administrator Certificate, and a Facility Sketch. Provider Information Notices are available and able to be presented to Staff, residents, visitors, and accessible to LPA upon request during the inspection process. No deficiencies cited. Exit interview conducted. A copy of the report was issued to the facility.the state’s words, verbatim · CDSS document, Mar 12, 2024