Sacramento Senior Living

Allegation investigated: Staff do not ensure that resident is admistered their medication(s) according to physician's instructions.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski spoke with facility administrator Salote Lewis over the phone and explained the purpose of the visit. This investigation consisted of interviews with facility administrator Salote Lewis, two staff members (S1-S2), and four residents (R1-R4), review of resident records, and observation. LPA Moleski reviewed medication administration records (MARs), centrally stored medication records, and medication labels for R1. During a visit on September 21, 2023, LPA Moleski observed that a nighttime dose of antibiotic medication was not given to R1 on the evening of September 1, 2023, according to R1’s MARs. All other nighttime medications were administered on that date, according to the MARs. [continued on 9099-C Substantiated During that same visit, LPA Moleski observed signatures missing for nighttime doses of three medications listed for the evening of September 20, 2023, and for daytime doses of two medications for the morning of September 20, 2023. During a visit on October 5, 2023, LPA Moleski observed four of R1’s medication bottles empty. S1 said staff had called to order refills but the pharmacies were running late. One of these medications, a 30-tablet bottle of an antibiotic, was started on September 2, 2023, according to R1’s centrally stored medication records. R1 was to take one tablet daily. According to R1’s MARs, R1 was given a dose of this medication each day from September 2, 2023 through October 3, 2023. Based on the start date recorded in R1’s centrally stored medication records, and based on the doses recorded in R1’s MARs, this medication should have run out on September 31, 2023, not on October 3, 2023. During the same visit on October 5, 2023, LPA Moleski observed in R1’s centrally stored medication records that R1 started a 30-capsule bottle of medication on September 2, 2023. This medication was not listed on R1’s MARs for the month of September. LPA Moleski reviewed hospital discharge orders for R1 from a hospital visit dated August 21, 2023 to September 1, 2023 which discontinued the medication. On R1’s MARs for October 2023, R1 was given daily doses of the medication from October 1 to October 5, according to the MARs. During the same visit on October 5, 2023, LPA Moleski interviewed a staff member (S1). S1 said R1 was not given doses of the medication from October 1, 2023 through October 3, 2023, and admitted to falsely marking the MARs as if medication had been given, though none was. S1 said there was no new start order for the medication. LPA Moleski interviewed a second staff member (S2). S2 said R1 had been given doses of the discontinued medication on October 4, 2023 and October 5, 2023. During the same visit on October 5, 2023, LPA Moleski observed that only two capsules of the medication remained of the 30-capsule bottle. Based on doses signed off in R1’s MARs, a minimum of 25 capsules should have remained as of October 5, 2023. S1 said S1 flushed an unknown quantity of capsules at an unspecified date. S1 said there were no witnesses to this act. R1’s medication destruction records were blank as of October 5, 2023. [continued on 9099-C] The department has determined the following as it relates to the allegation that staff do not ensure that resident is administered their medication(s) according to physician's instructions: Based on interviews, record review, and observation, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is being cited per 22 CCR Section 87465(a)(4). Due to being a repeat violation, a civil penalty in the amount of $250 was assessed. An exit interview was held with Lewis. Appeal rights and a copy of this report were left with staff member Eliesa Qiolele. The department has determined the following as it relates to the allegation that staff are discriminating against resident: Based on interviews, the above allegation is UNFOUNDED. A finding that the complaint allegation is unfounded means the allegation is false, could not have happened or is without a reasonable basis. An exit interview was held with Lewis and a copy of this report was left with staff member Eliesa Qiolele.the state’s words, verbatim · CDSS document, Oct 24, 2023 · control 27-AS-20230915165919

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 25, 2023

"The licensee shall assist residents with self-administered medications as needed." This requirement was not met as evidenced by: Based on observation, record review, and interviews, R1 was not given medication in accordance with doctor's orders, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Licensee agrees to conduct a staff training regarding medication administration. Licensee shall send LPA Moleski a sign-in sheet for this training and send a copy to LPA Moleski. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit in order to address deficiencies discovered during a complaint investigation. LPA Moleski spoke with facility administrator Salote Lewis over the phone and explained the purpose of the visit. During the course of a complaint investigation, LPA Moleski interviewed a staff member (S1). S1 told LPA Moleski that S1 flushed an unknown quantity of a resident's (R1) medication on an unknown date. During a complaint investigation visit on October 5, 2023, LPA Moleski observed in R1’s centrally stored medication records that R1 started a 30-capsule bottle of medication on September 2, 2023. This medication was not listed on R1’s MARs for the month of September. LPA Moleski reviewed hospital discharge orders for R1 from a hospital visit dated August 21, 2023 to September 1, 2023 which discontinued the medication. On R1’s MARs for October 2023, R1 was given daily doses of the medication from October 1 to October 5, according to the MARs. During the same visit on October 5, 2023, LPA Moleski interviewed a staff member (S1). S1 said R1 was not given doses of the medication from October 1, 2023 through October 3, 2023, and admitted to falsely marking the MARs as if medication had been given, though none was. S1 said there was no new start order for the medication. LPA Moleski interviewed a second staff member (S2). S2 said R1 had been given doses of the discontinued medication on October 4, 2023 and October 5, 2023. During the same visit on October 5, 2023, LPA Moleski observed that only two capsules of the medication remained of the 30-capsule bottle. Based on doses signed off in R1’s MARs, a minimum of 25 capsules should have remained as of October 5, 2023. S1 said S1 flushed an unknown quantity of capsules at an unspecified date. S1 said there were no witnesses to this act. R1’s medication destruction records were blank as of October 5, 2023. This facility is being cited per 22 CCR Section 87465(i). An exit interview was held with Lewis. Appeal rights and a copy of this report were left with staff member Eliesa Qiolele.the state’s words, verbatim · CDSS document, Oct 24, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(i) · Plan of correction due date: Oct 25, 2023

"(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following:" This requirement was not met as evidenced by: Based on observation and interview with S1, S1 destroyed an unknown amount of R1's medications without witnesses, and without the presence of the facility administrator, and without recording the destruction as required, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Licensee agrees to conduct a staff training regarding medication destruction. Licensee shall send LPA Moleski a sign-in sheet for this training and send a copy to LPA Moleski. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Incident

On 10/20/23 at 1:30 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to conduct a case management regarding an AWOL incident which occurred on 10/13/2023. LPA Lee met with direct care staff, Dillon Williams, who then called administrator, Salote Lewis to informed that Community Care Licensing Department (CCLD) is present in the facility. LPA Lee explained the purpose of the visit. The census is 4 resident with one facility staff. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. At 2:00 PM, LPA Lee toured the facility with direct care staff, Dillon Williams, to ensure the safety of the residents. LPA interviewed direct care staff, Dillon and reviewed incident report dated 10/16/2023. LPA Lee also reviewed (R1) LIC 625, Needs and Services and LIC 602 Physician's Report. Based on interview and record review it was determined that R1 exited the facility front door on 10/13/2023. Moreover, it was also learned that while staff 1 (S1) was doing rounds to check on the residents (S1) did not see (R1) in (R1) room or anywhere in the facility. Law enforcement was called, and a missing person report was filed. R1's LIC 602, Physician Report dated 09/25/2023 was reviewed by LPA Lee and it revealed that (R1) is unable to leave the facility unassisted. Interview with Administrator revealed facility's internal plan includes providing supervision for R1 and all other residents in care. Additionally, it was revealed through interview that R1 left the facility, and no facility staff was aware of (R1) whereabouts. It was also discovered that (R1) was approximately 0.8 miles away from the facility when law enforcement found (R1) and brought (R1) back to the facility. Based on today's case management, a citation is issued under Title 22, Division 6. An immediate civil penalty in the amount of $500 is issued in addition to citation due to absence of supervision. An exit interview was conducted with direct care staff, Dillon Williams. A copy of this report LIC 809, LIC 809-D and appeal rights was provided to direct care staff at the end of the visit.the state’s words, verbatim · CDSS document, Oct 20, 2023

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(d) · Plan of correction due date: Oct 27, 2023

1569.312(d)Basic services requirements: Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement was not met as evidence by: Based on file reviews and interviews, the Licensee did not ensure staff were aware of R1 general whereabouts as R1 was found by a law enforcement and returned R1 to the facility. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Oct 20, 2023

Plan of correction: Facility Administrator agrees to conduct elopement drill and training for all staff by POC date 10/18/2023. Facility Administrator will also submit a plan to ensure residents general whereabouts are known by staff. Plans to include , but not limited to: location within the facility and documentation to indicate when checks are completed. Facility administrator will email LPA Lee pang.lee@dss.ca.gov POC by POC due date 10/27/2023 by 5 PM.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Salote Lewis and explained the purpose of the visit. During a visit on 9/21/23, LPA Moleski reviewed residents' medication administration records (MARs). LPA Moleski observed the initials "IN" signing off on medication administrations on September 15 through September 17, 2023. During a visit on 9/21/23, LPA Moleski interviewed a staff member (S1) about who the initials belonged to. S1 said they belonged to an individual (S2) who filled in for S1 while S1 was out. S1 said he worked with S2 for one day, and S2 worked on their own afterward. During a visit on 9/21/23, LPA Moleski interviewed a resident (R1) who said an individual (S2) worked as a caregiver for a total of three days at this facility. During a visit on 9/21/23, LPA Moleski reviewed the Licensing Information System (LIS). The only individuals associated to this facility as of 9/21/23 were facility administrator Salote Lewis and S1. During an interview on 9/26/23, Lewis said this individual (S2) works on the weekends. Lewis provided this individual's full legal name. Lewis said S2 has a criminal record clearance. During an interview, on 9/21/23, S1 said that R2 suffered a fall on or around August 21, 2023, and was hospitalized until September 1, 2023. During interviews on 9/21/23, R1 and R2 both said that R2 had suffered a fall. LPA Moleski did not receive an incident report regarding R2's fall or hospitalization. [continued on 809-C] LPA Moleski reviewed discharge notes from R2's hospital visit dated 8/21/23 to 9/1/23. This facility is being cited per 22 CCR Sections 87355(e)(2) and 87211(a)(1)(D). An immediate civil penalty of $100 a day for three days, for a total of $300, is being assessed for a criminal record clearance deficiency. An exit interview was held and a copy of this report was left with Lewis.the state’s words, verbatim · CDSS document, Sep 26, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Sep 27, 2023

Criminal Record Clearance: "(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: ... ...(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or" This requirement was not met as evidenced by: Based on record review and interviews, an individual who was not cleared worked in this facility for at least three days, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Sep 26, 2023

Plan of correction: Licensee agrees to associate S2 by the POC due date. Licensee agrees to email LPA Moleski confirming S2 has been associated. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Oct 3, 2023

Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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 in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident." This requirement was not met as evidenced by: Based on interviews and record review, R2 fell and was hospitalized between 8/21/23 and 9/1/23, and an incident report was not received reporting this event, which poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Sep 26, 2023

Plan of correction: Licensee agrees to review Title 22 reporting requirements and to write a statement of acknowledgment that these requirements have been reviewed. Licensee agrees to email LPA Moleski a copy of this statement. vincent.moleski@dss.ca.gov

Type of visit: POC

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a plan of correction (POC) visit. LPA Moleski met with facility administrator Salote Lewis and explained the purpose of the visit. LPA Moleski cited this facility on 8/21/23 after LPA Moleski learned that a resident (R1) did not have a medical assessment (LIC 602) completed within a year of admission. During that visit, LPA Moleski and Lewis agreed upon a plan of correction due date of 9/18/23. Lewis acquired a new LIC 602 on 9/21/23. A civil penalty for failure to correct this deficiency is being assessed. The civil penalty for failure to correct this deficiency is $100 a day for three days, for a total of $300. An exit interview was held and a copy of this report, along with a copy of the LIC 421FC generated for this civil penalty, was left with Salote.the state’s words, verbatim · CDSS document, Sep 26, 2023

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a postlicensing inspection. LPA Moleski met with facility administrator Salote Lewis and explained the purpose of the visit. LPA Moleski reviewed Lewis' file, a staff member's file (S1) and two resident files (R1-R2). This facility currently has two residents. R1 is age 75. R2 is age 34. Less than 75 percent of this facility's residents are over the age of 60. R1 was admitted on 8/8/23, according to R1's admission agreement. R1's admission agreement was not signed by R1 or a responsible party as of this visit date. R1's LIC 602 is dated 7/1/2022, which is more than a year prior to admission. R1's Identification and Emergency Information form is blank and is unsigned, and therefore did not contain a name, address, or phone number of a physician and dentist to be called in an emergency. Lewis said she had not received completed and signed documents back from R1's conservator. While reviewing medication administration records (MARs), LPA Moleski observed two missed doses for R1. R1 did not receive a nighttime dose of one medication on 8/8/23, and did not receive a midday dose of a different medication on 8/17/23, according to the MARs. LPA Moleski toured the facility with Lewis and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 70 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 116 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. [continued on 809-C] While inspecting a facility bathroom, LPA Moleski and Lewis observed a bottle of toilet bowl cleaner left in an unlocked cabinet. While inspecting the backyard, LPA Moleski and Lewis observed an unlocked shed containing unsecured cans of paint and bags of drywall joint compound. LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked closet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives. LPA Moleski interviewed one staff member (S1) and two residents (R1-R2). This facility is being cited per the applicable 22 CCR Sections. An exit interview was held with Lewis. Appeal rights and a copy of this report were left with Lewis.the state’s words, verbatim · CDSS document, Aug 21, 2023

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Vincent Moleski arrived announced to conduct a prelicensing inspection at this home. LPA Moleski met with Salote Lewis and explained the purpose of the visit. LPA Moleski reviewed Lewis's application documents, fire clearance and floor plan. The home is cleared for six non-ambulatory residents. Lewis's administrator certificate number is 6062098740 and it expires 8/8/24. LPA Moleski toured the home with Lewis and inspected common areas, kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 69 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature was tested and measured 110 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked closet in a caregiver room for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives. LPA Moleski conducted Component III Orientation with Lewis. No deficiencies were observed during this visit. Prelicensing is complete for this applicant. An exit interview was conducted and a copy of this report was left with Lewis.the state’s words, verbatim · CDSS document, Jun 21, 2023