Walnut House

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an unannounced quarterly on-site visit regarding the Stipulation and Waiver and Order adopted on 05/23/2022. LPA met with Lacy Berry, Administrator, and explained the purpose of the visit. During today's visit, LPA was provided the Compliance Binder, and observed a copy of the Stipulation in the binder. LPA observed Care Plan Reviews to last be conducted on 10/12/2023. LPA observed recent quarterly training to be conducted on 8/22 Fall Reduction, 9/26 Changes in Condition, 10/18 Dementia Care, along with printouts of PowerPoint presentation. LPA observed documentation of the last quarterly visit conducted by Solar Senior Living representative, Jonathan Harris, to be on August 8, 2023. LPA informed Administrator LPA will discuss with Licensing Program Managers if quarterly visits with Solar Senior Living and Ciminocare are to be conducted in tangent, as LPA observed the current quarterly visit to be offsetting. LPA obtained a copy of Solar Senior Living and Ciminocare Quarterly Visits log, and statements from 07/27/2022 to 08/08/2023. LPA observed no quarterly audit has been conducted by Allen Flores Consulting Group since LPA's last quarterly visit conducted on 8/23/2023 as the most recent audit was completed on 8/17/2023. LPA is requesting a copy of facility's LIC 309 ADMINISTRATIVE ORGANIZATION. Additionally, LPA is requesting a copy of the most recent quarterly audit conducted by Allen Flores Consulting Group on 8/17/2023. All documents are to be submitted to LPA by close of business 11/15/2023. If by 11/15/2023, no new audit has been completed by Allen Flores Consulting Group, LPA is requesting a copy of the new audit once available. Exit interview conducted. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Nov 8, 2023

Allegation investigated: Facility is in disrepair and unsanitary

On 10/11/2023, Licensing Program Analyst (LPA) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to open the complaint the Department received regarding the allegation cited above. LPAs met with Administrator, Lacy Berry, and explained the purpose of the visit. During the investigation, LPAs conducted an inspection of three bathrooms, interviewed two residents, and took 13 photos. The result of the investigation is as follow. Please continue on LIC 9099-C... Substantiated Allegation: Facility is in disrepair and unsanitary. On 10/11/2023, the Department conducted an inspection of R1's previous room and observed the bath tub faucet to be leaking while it was not in use. Interview conducted with R1 revealed that although R1 is not currently living in that room, the leaking has been ongoing prior to his temporary move to the room next door. R1 stated the reason why is was moved is not related to the leaking issue. Interview further revealed that R1 has informed Maintenance of this issue for months but it was never resolved. R1 stated the leak has caused molding in the tub when he used to reside in the room. Based on LPAs' observation, LPAs were able to see the leak has not been fixed and observed black and brown discoloration in the tub. Based on LPAs observation of R1's current room, it revealed the bed frame to be in disrepair as the headboard was not correctly mounted to the wall, causing it to be slanted approximately eight inches away from the wall. Interview with R1 revealed it is a safety hazard as the headboard is not properly secured. Additionally, based on observation of R1's current room, LPAs observed a strong odor of urine. Observation of R1's current bathroom revealed the bathroom floor to have multiple discoloration around the toilet. Interview with R1 revealed facility did not have housekeepers for months, so caregivers were in charge of the bathroom cleaning. Interview further revealed that the last housekeeping conducted, caregiver did not properly clean the bathroom floor. Based on the allegation, facility is in disrepair and unsanitary, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegation cited above is substantiated, please see LIC9099-D. Exit interview conducted, and a copy of the report and appeal rights was provided via email as LPAs experienced technical difficulties.the state’s words, verbatim · CDSS document, Oct 11, 2023 · control 59-AS-20231010142402

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Oct 12, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation, Licensee did not comply with the regulation above as LPA Yang and LPA Ratajczak observed R1's room to have a strong odor of urine, unsecured headboard and multiple discoloration on bathroom floor, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 11, 2023

Plan of correction: Housekeeper was asked to clean R1's room and bathroom immediately. Licensee will notify LPA Yang when headboard and bathroom faucet is fixed. This matter will be discussed during office meeting with Licensees.

Allegation investigated: Staff did not ensure that medications are inaccessible to residents in care.

On 10/11/2023, Licensing Program Analyst (LPA) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to open the complaint the Department received regarding the allegation cited above. LPAs met with Administrator, Lacy Berry, and explained the purpose of the visit. During the investigation, LPAs conducted an inspection of R1's room and conducted file review of R1's records. The result of the investigation is as follow. Please continue on LIC 9099-C... Substantiated Allegation: Staff did not ensure that medications are inaccessible to residents in care. The Department conducted interviews regarding the allegation. Interview conducted with Administrator revealed medications are centrally stored. Based on LPAs' observation conducted on 10/11/2023, it revealed R1 has medication in her room. LPAs observed the medication was in a lockbox located in her bathroom. Interview conducted with R1 revealed R1 has frequent nausea and keeps the medication in her room because she is unable to get staff assistance in a timely manner. LPAs observed the medication found to be Ondansetron 4mg which is often used to nausea and vomiting. Based on R1's most recent LIC 602 PHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY on file, date of exam 06/22/2021, LPAs observed that R1 is unable to administer own prescription medications, R1 is unable to administer own PRN medications, and additionally, LPAs observed R1 is unable to store own medications. Based on the allegation, staff did not ensure that medications are inaccessible to residents in care, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegation cited above is substantiated, please see LIC9099-D. Exit interview conducted, and a copy of the report and appeal rights was provided via email as LPAs experienced technical difficulties.the state’s words, verbatim · CDSS document, Oct 11, 2023 · control 59-AS-20230829093013

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Oct 12, 2023

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on LPAs' observation and interview with R1, Licensee did not comply with the section above as LPA Yang and LPA Ratajczak observed R1 to have Ondansetron in her room, which poses an immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Oct 11, 2023

Plan of correction: Medication is to be removed immediately and centrally stored. This matter will be discussed in office meeting with Licensees.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff dispensed the wrong medication to a resident while in care.

Licensing Program Analaysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced to continue the investigation for the complaint the Departmenet received on 9/5/2023. LPAs met with Administrator, Lacy Berry, and explained the purpose of the visit. During the course of this investigation, the Department conducted interviews, file reviews and a medication audit of R1. The result of the investigation is as follow. Please continue on LIC 9099-C** Substantiated Allegation: Staff dispensed the wrong medication to a resident while in care. Based on LPAs' medication audit conducted on 09/28/2023, the audit included comparing R1's Medication Administration Record (MAR) with R1's medications, medication start dates and physician’s orders. During LPAs' medication count, (1) staff med tech was present at all times. Based on the medication audit conducted, file review of R1's MAR revealed on September 4th and September 5th, PM med tech did not sign that medications were administered to residents in care. LPAs conducted a medication count with S1 of R1's Glipizide. LPAs observed R1's physician order for Glipizide is to take two tablets by mouth two times a day 30 minutes before meals. LPAs observed bottle start date to be 8/31. During medication count, LPAs and S1 observed the Glipizide bottle of 120 tablets to have 11 tablets remaining, which means 109 tablets has been dispensed. Based on the signatures and/or initials on the R1's August 2023 and September 2023, total medication signed off totaled to 108 tablets, two tablets on AM shift of August 31, 2023 and 106 tablets month of September 2023. LPAs and S1 observed one tablet to be missing from R1's medication bottle and not accounted for. Based on the allegation, staff dispensed the wrong medication to a resident while in care, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegation cited above is substantiated, please see LIC9099-D. Exit interview conducted, copy of report and appeal rights was provided to Administrator.the state’s words, verbatim · CDSS document, Sep 28, 2023 · control 59-AS-20230905164434

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 29, 2023

87465 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 is not met as evidenced: Based on observation of medication audit, Licensee comply to the section cited above as LPAs observed R1's medication to have one tablet missing from the original bottle which was also not signed off on the MAR, which poses an immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: An office meeting will be held to discuss this matter. LPA will reach out to Administrator and Licensee representatives to schedule a meeting.

Type of visit: POC

On 9/7/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Plan of Correction (POC) visit regarding the deficiencies LPA cited the facility on August 24, 2023 for complaint Control Number 25-AS-20220926150347 and Control Number 25-AS-20230120114145. LPA met with Administrator, Lacy Berry, and explained the purpose of the visit. LPA explained to Administrator that failure to correct plan of correction by the given due date could and will result to $100 per day until corrected civil penalty. LPA additionally informed Administrator that POC may be extended if requested by Licensee. Administrator informed LPA she was off for a few days and had forgotten to submit POC to LPA prior to leave. During today's visit, LPA cleared the following POC as LPA received the POC via email the day prior to visit at 7:34PM: CCR 87465(a)(4) 87465 Incidental Medical and Dental Care CCR 87468.1(a)(1) 87468.1 Personal Rights of Residents in All Facilities As a result of today's inspection, civil penalties were assessed. Exit interview conducted and a copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 7, 2023

Allegation investigated: Staff are mismanaging residents medication.

On 08/24/2023, Licensing Program Analyst (LPA) Cassie Yang and Licensing Program Manager (LPM) Laura Munoz arrived unannounced at the facility to deliver finding of the allegation cited above. LPA and LPM met with Administrator, Lacy Berry, and explained the purpose of the visit. During the course of this investigation, the Department conducted extensive interviews, file review, and conducted a medication audit. The result of the investigation is as follow. **Please continue on LIC 9099-C** Substantiated Allegation: Staff are mismanaging residents medication On 08/23/2023, LPA and LPM conducted an audit of the medication room of the facility. The audit included comparing Medication Administration Records (MARs) with resident’s medications, medication start dates and physician’s orders. Additionally, LPM, with facility staff present, conducted a medication count of residents controlled medications. Based on the medication audit conducted, MARs showed PM staff did not sign that medications were administered to residents in rooms #1-47. Days of missing signatures ranged from 3-6 days from the date of inspection. A sample of resident’s medications were compared to the MAR signatures and the medication start dates. R1’s medications were reviewed and revealed that R1 had a medication ordered on 08/07/2023 which was to be given 3 times a day. Based on the medication count, facility staff failed to administer R1 16 doses of medication. R2’s medications were reviewed and revealed that R1 had a medication that started on 08/14/2023 which was to be given 2 times a day. Based on the medication count, facility staff failed to administer R2 9 doses of medication. LPM and LPA conducted the medication audit with the facility Administrator, Lacy Berry, and Regional Director, Robert Godfrey present. Based on the allegation, staff are mismanaging residents medication, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency cited on LIC9099D. Exit interview. Copy of report and appeal rights was provided to Administrator.the state’s words, verbatim · CDSS document, Aug 24, 2023 · control 25-AS-20220926150347

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

87465 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... 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 is not met as evidenced by: Based on observation during medication audit, Licensee did not ensure medications were administered, as LPA and LPM observed MARs was not sign if medications were administered to residents, Rooms #1-47. Days of missing signatures ranged from 3-6 days from the date of inspection, which poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Aug 24, 2023

Plan of correction: Licensee is to schedule a training for all Med Techs of how to complete the Medication Administration Record (MAR) correctly. Please notify LPA the date of training by Friday 8/25/2023. Licensee is to provide CCLD a copy of the training materials and list of attendees by Thursday 8/31/2023.

Allegation investigated: Facility is not following resident care plan.

Licensing Program Analyst (LPA) Cassie Yang and Licensing Program Manager (LPM) Laura Munoz arrievd unannounced at the facility to deliver findings of the allegations cited above. LPA and LPM met with Administrator, Lacy Berry, and explained the purpose of the visit. During the course of this investigation, the Department conducted extensive interviews and file review. The result of the investigation is as follow. Please continue on LIC 9099-C** Unfounded Allegation: Facility is not following resident care plan. The Department conducted a file review, it revealed R1 needed assistance with transfer based on needs and service plan from December 2022. The Department observed no notes and/or documentation regarding turning every two hours was observed in R1's care plan. Based on interviews conducted on 5/8/2023, facility staff stated there are no residents in care that required a two-hour turning. Based on information obtained through interviews and file reviewed, the Department finds the allegation found the complaint to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of report and appeal rights was provided. Allegation: Facility does not provide medication as prescribed. Based on LPA and LPM's medication audit conducted on 08/23/2023, the audit included comparing Medication Administration Records (MARs) with resident’s medications, medication start dates and physician’s orders. Additionally, LPM, with facility staff present, conducted a medication count of residents controlled medications. Based on the medication audit conducted, MARs showed PM staff did not sign that medications were administered to residents in rooms #1-47. Days of missing signatures ranged from 3-6 days from the date of inspection. A sample of resident’s medications were compared to the MAR signatures and the medication start dates. R1’s medications were reviewed and revealed that R1 had a medication ordered on 08/07/2023 which was to be given 3 times a day. Based on the medication count, facility staff failed to administer R1 16 doses of medication. R2’s medications were reviewed and revealed that R1 had a medication that started on 08/14/2023 which was to be given 2 times a day. Based on the medication count, facility staff failed to administer R2 9 doses of medication. LPM and LPA conducted the medication audit with the facility Administrator, Lacy Berry, and Regional Director, Robert Godfrey present. Based on the allegation, staff are mismanaging residents medication, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegations cited above are substantiated, but no deficiency will be as LPA substantiated the same allegation for complaint 25-AS-20220926150347 on 8/24/2023. Exit interview conducted, copy of report and appeal rights was provided to Administrator.the state’s words, verbatim · CDSS document, Aug 24, 2023 · control 59-AS-20230428133225

Allegation investigated: Staff mismanaged resident medication. Resident not being provided medication as prescribed.

On 08/24/2023, Licensing Program Analyst (LPA) Cassie Yang and Licensing Program Manager (LPM) Laura Munoz arrived unannounced at the facility to deliver findings of the allegations cited above. LPA and LPM met with Administrator, Lacy Berry, and explained the purpose of the visit. During the course of this investigation, the Department conducted extensive interviews, file review, and conducted a medication audit. The result of the investigation is as follow, please continue on LIC 9099-C** Substantiated Allegation: Staff mismanaged resident medication. Allegation: Resident not being provided medication as prescribed. On 08/23/2023, LPA and LPM conducted an audit of the medication room of the facility. The audit included comparing Medication Administration Records (MARs) with resident’s medications, medication start dates and physician’s orders. Additionally, LPM, with facility staff present, conducted a medication count of residents controlled medications. Based on the medication audit conducted, MARs showed PM staff did not sign that medications were administered to residents in rooms #1-47. Days of missing signatures ranged from 3-6 days from the date of inspection. A sample of resident’s medications were compared to the MAR signatures and the medication start dates. R1’s medications were reviewed and revealed that R1 had a medication ordered on 08/07/2023 which was to be given 3x a day. Based on the medication count, facility staff failed to administer R1 16 doses of medication. R2’s medications were reviewed and revealed that R1 had a medication that started on 08/14/2023 which was to be given 2x a day. Based on the medication count, facility staff failed to administer R2 9 doses of medication. LPM and LPA conducted the medication audit with the facility Administrator, Lacy Berry, and Regional Director, Robert Godfrey present. Based on the allegation, staff are mismanaging residents medication, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegations cited above are substantiated, but no deficiency will be as LPA substantiated the same allegation for complaint 25-AS-20220926150347 on 8/24/2023. Exit interview conducted, copy of report and appeal rights was provided to Administrator. Allegation: Facility has mold Based on observation conducted on 4/7/2023, LPA's observed the shower room to have the smell of cleaning solution. LPA's observed the tiles to have discoloration but did not observed any presence of molding. Based on observation conducted on 08/23/2023, LPM observed the resident shower rooms did not appear to have presence of any mold. LPM informed facility the showers in the facility are in need a deep clean due to the age and use of the shower areas. Based on interviews conducted by LPA, it revealed Maintenance Supervisor cleans the shower room weekly when needed. Interviews further revealed the facility and/or shower room are "older and not updated" so the tiles may be worn out but not in disrepair. Based on information obtained through interviews and file reviewed, the Department finds the allegation found the complaint to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of report and appeal rights was provided.the state’s words, verbatim · CDSS document, Aug 24, 2023 · control 59-AS-20230405141003

Allegation investigated: Staff do not treat residents with dignity and respect.

On 08/24/2023, Licensing Program Analyst (LPA) Cassie Yang and Licensing Program Manager (LPM) Laura Munoz arrived unannounced at the facility to deliver finding for the allegation cited above. LPA and LPM met with Administrator, Lacy Berry, and explained the purpose of the visit. During the course of this investigation, the Department conducted extensive interviews. The result of the investigation is as follow. **Please continue on LIC 9099-C** Substantiated LIC 9099-C... Allegation: Staff do not treat residents with dignity and respect. Based on interviews the Department conducted, it revealed R1 stated PM shift staff does not treat residents in care with respect. Interview conducted with R2, R3, and R4 revealed staff are rude and disrespectful. R2 clarified it is the PM staff who are rude. Interview conducted with S1 revealed that S1 has witnessed a PM staff being rude saying "That's not my job, I pass out meds only" when asked to notify resident's primary care physician regarding their medication. Based on the allegation, staff are mismanaging residents medication, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency cited on LIC9099D. Exit interview conducted, a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Aug 24, 2023 · control 25-AS-20230120114145

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Sep 1, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews conducted, Licensee did not ensure residents in care to be accorded dignity, as residents informed LPA and LPM the PM shift staffs are rude and disrespectful, which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Aug 24, 2023

Plan of correction: Licensee is to provide all staff a training of residents rights. Licensee is to send CCLD a copy of the training materials and proof of attendees by Friday August 1, 2023.

Allegation investigated: Resident was verbally abused by staff. Facility does not ensure that residents are adequately fed. Resident being served raw food.

On 08/24/2023, Licensing Program Analyst (LPA) Cassie Yang and Licensing Program Manager (LPM) Laura Munoz arrived unannounced at the facility to deliver findings of the allegations cited above. LPA and LPM met with Administrator, Lacy Berry, and explained the purpose of the visit. During the course of this investigation, the Department conducted extensive interviews and observations. The result of the investigation is as follow. Please continue on LIC 9099-C** Unfounded Allegation: Resident was verbally abused by staff. The Department conducted interviews with residents regarding the allegation of verbal abuse by staff. Although resident’s interviewed indicated PM staff can be discourteous and curt, there were reports of staff verbally abusing residents in care. Based on information obtained through observation and interviews, the allegations listed above are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Allegation: Facility does not ensure that residents are adequately fed. Allegation: Resident being served raw food. The Department conducted a tour of the kitchen in the facility and interviewed residents in care. Based on annual visit conducted on 08/24/2023, the facility served fried chicken, mash potatoes and gravy and cooked spinach. Based on interview conducted, it did not indicate residents has ever received raw, uncooked or under cooked food served at the facility. Based on information obtained through observation and interviews, the allegations listed above are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report and appeal rights was left with Administrator.the state’s words, verbatim · CDSS document, Aug 24, 2023 · control 59-AS-20230505093715

Type of visit: Case Management - Annual Continuation

On August 24, 2023 at 3:00 PM, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management annual continuation. LPA met with Regional Director, Robert Godfrey, and Administrator, Lacy Berry, and explained the purpose of the visit. Regional Director informed LPA that Administrator is currently in a meeting with Long Term Care Ombudsman and other facility staff to discuss resident care plan. Licensing Program Manager (LPM) Laura Munoz arrived to the facility shortly afterwards. During today's visit, LPA conducted resident interview and staff interviews. LPM conducted a resident and personnel file review and observed the files to be complete. LPM observed the fire extinguisher to be recently serviced. Additionally, LPM observed the facility to have 2+ days of perishable and 7+ days of nonperishable food present in the kitchen. Sharps and toxins were observed to be locked and secured. LPM observed call button to be missing in a resident's room. Administrator informed LPA that it was not notified to front desk and will provide a call light immediately to the room. LPA, LPM, Administrator and Regional Director discussed the concerns at the facility, House Rules and process of providing 30-day eviction notices. Additionally, LPA and Administrator discussed concerns regarding medication and staffing. LPA and LPM was informed Alan Flores Consultant Group Nurse Consultant will provide an on-site to conduct a full medication audit for the facility. As a result of today's visit, no deficiencies cited. Exit interview conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 24, 2023

Allegation investigated: Staff do not keep the facility clean and sanitary.

Licensing Program Analyst (LPA) Cassie Yang and Licensing Program Manager (LPM) Laura Munoz arrived unannounced to deliver complaint findings to a complaint the Department received on 12/08/2022. LPA and LPM met with Administrator, Lacy Berry, and explained the purpose of the visit. During the course of the investigation, the Department interviewed Administrator, Long Term Care Ombudsman (LTCO) Ronald Carrera, (2) residents (R1 and R2) and (2) family member of resident (R1). Additionally, the Department conducted extensive record reviews, including but not limited to, R1’s physician report for RCFE, R1’s Needs and Service Plan, R2’s physician report for RCFE, R2’s Needs and Service Plan, LTCO’s complaint report and Sacramento County Sheriff Department Report. **Please continue on LIC 9099-C** Unfounded LIC 9099-C The result of the investigation is as follow: Allegation: Resident engaged in sexual interactions with another resident in care. Based on interview conducted with Administrator revealed R1 and R2 are just friends who often go on walks and read books together. Administrator denied seeing R1 and R2 being inappropriate and/or knowing if R1 and R2 go to each other’s room. Based on interview with R1 revealed R1 was unable to remember the name of the current President of the United States and the current year. R1 stated R2 is a friend. Interview with R1 revealed R1 is unable to remember if R1 and R2’s “physical relationship” was a dream or real but confirmed R1 and R2 consented. Based on interview conducted with R2 revealed R2 was unable to state R2’s age, address, and/or the current President of the United States. R2 stated it “rings a bell” when asked if R1 and R2 are friends. Based on interviews conducted with R1’s family members revealed R1 may be delusional as a result of R1’s urinary tract infection and dementia. Interview further revealed R1 and R2’s relationship was a “platonic relationship” as R2 is R1’s “buddy”. Based on records review, it revealed that R1 was not having consensual and non-consensual sex with anyone. R1 indicated R1 does not have any issues with R2. Based on information obtained through interviews and records reviewed, the Department finds the allegation to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report and appeal rights was left with Administrator.the state’s words, verbatim · CDSS document, Aug 23, 2023 · control 25-AS-20221208121756

Allegation investigated: Staff do not keep the facility clean and sanitary.

Licensing Program Analyst (LPA) Cassie Yang and Licensing Program Manager (LPM) Laura Munoz arrived unannounced to deliver complaint finding to a complaint the Department received on 02/14/2023. LPA and LPM met with Administrator, Lacy Berry, and explained the purpose of the visit. During this investigation, the Department conducted extensive interviews and file review. The result of the investigation is as follow, please continue on LIC 9099-C** Unfounded Allegation: Staff do not keep the facility clean and sanitary. Based on interview conducted with Administrator revealed there is a vacancy in the housekeeping position. Administrator stated a position has been offered but pending on individual’s background clearance. Administrator stated Administrator, S1, S2 and S3 has been on rotation for housekeeping duties every day of the week since housekeeping is weekly. Administrator stated morning caregivers provide daily bed-making. Based on interview conducted with S1, S1 confirmed S1 has been doing vacuuming and bathroom cleaning to fulfill housekeeping duties until a new housekeeper is hired. Based on interview with S2 and S3 also revealed they have been completing housekeeping duties. The Department conducted a file review which revealed that in the Admission Agreement, Revised 10/2019, on Page 3 under Housekeeping confirmed housekeeping services are provided once a week. LPA observed additional housekeeping services is offered upon request for an extra fee. Based on information obtained through interviews and file reviewed, the Department finds the allegation found the complaint to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report and appeal rights was left with Administrator.the state’s words, verbatim · CDSS document, Aug 23, 2023 · control 25-AS-20230214135709

Allegation investigated: Facility staff are restricting resident's personal activities.

Licensing Program Analyst (LPA) Cassie Yang and Licensing Program Manager (LPM) Laura Munoz arrived unannounced to deliver complaint findings to a complaint the Department received on 01/23/2023. LPA and LPM met with Administrator, Lacy Berry, and explained the purpose of the visit. During this investigation, the Department conducted interviews and file review. The result of the investigation is as follow, please continue on LIC 9099-C** Substantiated LIC 9099-C Allegation: Facility staff are restricting resident's personal activities. The Department has conducted interviews and record review for the allegation cited above. Based on the interview with Administrator on 1/26/2023, it revealed there was conflict regarding residents exiting the dining room sliding door to go outside to smoke. Interview with Administrator revealed Long Term Care Ombudsman was involved and advised the facility to implement a smoking schedule of 10 minutes after each meal to create fairness to all residents in care. Based on interview conducted with R1 revealed it was not true that staff are restricting residents to one cigarette per hour, but facility is enforcing a smoke schedule for after meals. Based on file review conducted, LPA reviewed the House Rule in the Admission Agreement. File review revealed under section “Smoking” to only state “There is no smoking within the facility. There are designated smoking areas that both residents and staff shall use.” The file review does not reveal a rule on smoking during mealtime. Based on information obtained through Facility Administrator, R1 and file reviewed, the Department finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency cited on LIC9099D. Exit interview. Copy of report and appeal rights was provided to Administrator.the state’s words, verbatim · CDSS document, Aug 23, 2023 · control 25-AS-20230123151735

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(6) · Plan of correction due date: Aug 30, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility. This requirement is not met as evidenced by: Based on interviews and file review, Licensee did not ensure that residents have the rights to make choices concerning their daily lives in the facility as smoking residents are to wait 10 minutes after mealtime in able to go outside to smoke, which poses a potential health safety and personal rights risk to residents in care as it is not listed in the House Rules.the state’s words, verbatim · CDSS document, Aug 23, 2023

Plan of correction: Licensee is to submit an addendum to House Rules implementing the 10 minutes after mealtime smoking rule to CCLD by 8/30/2023. Licensee is to provide all residents in care the copy of the House Rule addendum immediately.

Allegation investigated: Facility did not issue a refund. Facility did not notify responsible party that resident relocated to another facility.

Licensing Program Analyst (LPA) Cassie Yang and Licensing Program Manager (LPM) Laura Munoz arrived unannounced to deliver complaint findings to a complaint the Department received on 01/18/2023. LPA and LPM met with Administrator, Lacy Berry, and explained the purpose of the visit. Please note, this report is amended to reflect current allegations. During this investigation, the Department conducted interviews and file review. The result of the investigation is as follow. **Please continue on LIC 9099-C** Unfounded Allegation: Facility did not issue a refund. The Department has conducted interviews and file review for the allegation cited above. Based on the interview with Administrator revealed resident (R1) was was sent out to the hospital for stroke-like symptoms end of June 2022. Administrator stated R1 was discharged to a skilled nursing facility while R1's personal belongings remained in her room at the facility. Interview with Administrator revealed R1's personal belongings were not removed from the facility until August 2022. Based on file review conducted revealed the Admission Agreement page 15, section Refund, states "Within twenty-one (21) business days after you vacate and remove all of your property from your Room, we shall refund to you or your estate any amounts we owe to you, minus (i) any Monthly Fees, fees for additional items and services, or other charges you owe to us..." The Department found the allegation to be unfounded. Allegation: Facility did not notify responsible party that resident relocated to another facility. The Department has conducted interviews and file review for the allegation cited above. Based on the interview with Administrator revealed resident (R1) does not have any responsible party listed in R1's file. Based on file review conducted, document revealed in R1's LIC 601 Identification and Emergency Information, signed and dated on 8/8/19, LPA observed "Self" listed in the "Responsible Person or Placement Agency". Based on information obtained through interviews and records reviewed, the Department finds the allegation to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report and appeal rights was left with Administrator.the state’s words, verbatim · CDSS document, Aug 23, 2023 · control 25-AS-20230118170306

Type of visit: Required - 1 Year

On 8/23/2023, Licensing Program Analyst (LPA) Cassie Yang and Licensing Program Manager (LPM) Laura Munoz arrived unannounced at the facility to conduct a Required 1- year annual inspection utilizing the CARE tool. LPA and LPM met with Administrator, Lacy Berry, and explained the purpose of the visit. Facility's census is 61, with two (2) residents on hospice services. Facility is licensed for 110 non-ambulatory, hospice waiver of 8. During today's visit, LPA Yang observed facility is currently under renovation. LPA Yang, LPM Munoz and Administrator observed (3) rooms to have a strong presence of urine smell from the hallway. LPM Munoz and Medical Technician reviewed the MAR and conducted medication counts for R1 and R2. LPA Yang took five (5) photos of medication, and obtained a copy of the MAR for R1 and R2. This observation is currently under review. At 2:30 PM, LPA Yang and Maintenance Supervisor toured two (2) rooms together to conduct temperature check and observed the sink water temperature to be at highest, 95.4*. Maintenance Supervisor informed LPA since the rooms are at the end of the wing, it may not be as hot as the other resident rooms. LPA was unable to complete the CARE tool during today's visit. Exit interview conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 23, 2023

Type of visit: Case Management - Legal/Non-compliance

On 8/23/2023, Licensing Program Analyst (LPA) Cassie Yang and Licensing Program Manager (LPM) Laura Munoz arrived unannounced at the facility to conduct an unannounced quarterly on-site visit regarding the Stipulation and Waiver and Order adopted on 05/23/2022. LPA and LPM met with Lacy Berry, Administrator, and explained the purpose of the visit. LPA was provided the Compliance Binder, and observed a copy of the Stipulation in the binder and at a conspicuous space by the front desk. During today's inspection, LPA observed two (2) missed weekly calls, week of 06/19/2023 and 06/26/2023, with Alan Flores Consulting Group, due to vacation from 6/21/2023-6/29/2023. LPA and Administrator discussed rescheduling the required calls to fulfill the condition of the Stipulation. LPA observed monthly staff needs review to last be conducted on 8/4/2023 with notation of hiring more caregiver and housekeepers. Administrator informed LPA there are no staffing concerns but would like to be overstaffed. LPA observed the recent quarterly clinical audit was conducted on 8/17/2023. LPA and Administrator discussed the details of documentation for End of Shift Report, and charting notes. As a result of today's visit, no deficiencies cited. Exit interview conducted. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Aug 23, 2023

Type of visit: Office

An office meeting was held on 05/24/2023 at 11:00 AM at the Sacramento North Regional Office on Goethe Road, Assistant Program Administrator (APA) Pam Gill, Regional Manager (RM) Alycia Berryman, Licensing Program Manager (LPM) Lauren Crocker and Licensing Program Analyst (LPA) Cassie Yang met with Licensee and facility representatives: Mark Cimino, Robert Godfrey and Adina Varareanu, to discuss the compliance history of the facility. The purpose of the meeting is to ensure facility is in substantial compliance with regulations and to discussed the depending applications for CiminoCare. Items discussed at the meeting included, but not limited to: 1. Additional Staff Training and Staffing 2. Compliance history 3. Content of stipulation in place 4. Current pending applications The licensee agrees to the following by close of business day Friday June 2, 2023: The licensee agreed to train staff on proactive listening, social and emotional training The licensee will submit a plan of resident level of care assessment and how staff are competent The licensee will submit a plan of how Administrator is collecting resident concerns and responding concerns in practice and/or in writing. CCLD agrees to the following: 1. Review the submitted plans and respond to CiminoCare within 72 hours. As a result, no deficiencies cited. Exit interview conducted and a copy of report was provided to Licensee.the state’s words, verbatim · CDSS document, May 24, 2023

Type of visit: Case Management - Other

On 5/11/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit. This is a joint visit with Long Term Care Ombudsman, Randy Dinning. LPA met with Administrator, Lacy Berry, and explained the purpose of the visit. Today's visit, LPA was invited and attended the resident council meeting and observed the topics discussed: -housekeeping -food menu -staffing Additionally, LPA toured the interior of the facility to ensure the health and safety of residents in care. LPA interviewed five (5) residents. LPA provided a copy of the Regulation 87224 Eviction Procedure to Administrator. No deficiencies cited. Exit interview conducted and a copy of the report was left at the facility with Administrator.the state’s words, verbatim · CDSS document, May 11, 2023

Allegation investigated: Resident was hit by another resident in care.

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Lacy Berry, to deliver findings into the complaint allegation listed above. During the investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Resident was hit by another resident in care ** Report continued on 9099-C ** Unsubstantiated Relevant party reported that resident (R1) had indicated that an individual at the facility hit them. A description of the suspect was provided to the Department. Interviews with staff members S1, S2, S3, S4, and S5, residents R2 and R3, and Administrator stated that they had not witnessed any incidents of a resident being hit at the facility. Interviews with the above individuals indicated that no one (resident nor staff) matching the description of the suspect provided to the Department has been at the facility. Interviews with relevant parties indicated that R1 was exhibiting behaviors of confusion around the time that incident was reported. LPA reviewed Home Health Care Notes and Special Incident Reports (SIRs) for R1. No documentation reviewed indicated any complaints about physical abuse. R1's Physician's Report for RCFE (LIC 602A) signed 9/23/2021 indicated R1 as having a primary diagnosis of Alzheimer's Disease unspecified. R1's LIC 602A dated 10/20/2022 indicated R1's primary diagnosis as an unstable burst fracture of first lumbar vertebra. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, May 4, 2023 · control 25-AS-20221201083301

Type of visit: Office

Licensing Program Analyst (LPA) CAssie Yang conducted a meeting via Microsoft Teams with Administrator, Lacy Berry, and CiminoCare Regional Director of Operations, Robert Godfrey, regarding the current concerns at the facility. LPA and facility representatives discussed the following: - resident council meeting - food/menu concerns - staffing concerns - resident on resident aggression - staff response time - current count of pending/open complaints At this time, LPA requested a copy of April 2023 menu and R1's call log as it was previously requested. LPA will submit a referral to technical support program for assistance with facility on high complaints. Exit interview conducted, a copy of the report will be emailed to Administrator for signature.the state’s words, verbatim · CDSS document, Apr 18, 2023

Type of visit: Case Management - Incident

On 2/24/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management regarding a call response concern reported to the Department. LPA met with Administrator, Lacy Berry, and explained the purpose of the visit. LPA was informed the call log system had recently stopped working, but was fixed the day of visit. LPA conducted an interview with Administrator, receptionist and (1) resident regarding the incident. During today's visit, LPA toured the interior of the facility and observed R1's private room. LPA requested a copy of R1's call log to be emailed to LPA by Friday March 3, 2023. Administrator informed LPA the system will be fixed approximately by next week. As a result of today's visit, no deficiencies were observed. Exit interview conducted and a copy of the report was emailed to Administrator.the state’s words, verbatim · CDSS document, Feb 24, 2023

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an unannounced quarterly on-site visit pursuant to a Stipulation and Waiver and Order adopted on 05/23/2022. LPA met with Lacy Berry, Administrator, and explained the purpose of the visit. During today's inspection, LPA observed a copy of the Stipulation in the binder and at a conspicuous place by the front desk. LPA reviewed the "Walnut House Compliance Binder" and observed to contain tab dividers for each requirement listed in the Stipulation and Waiver; and Order. LPA observed the weekly calls with Alan Flores Consulting Group to be completed weekly with the most recent call to be on 1/19/23. LPA observed the monthly task of reviewing residents service plan to be up to date from June 2022 to January 2023. LPA observed the monthly staffing needs call with Human Resources to be completed on 1/24/23. LPA observed the recent quarterly clinical audit was conducted on 1/5/2023 as well as an on-site visit on 10/11/2022. As a result of today's visit, no citations cited. Exit interview conducted. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Jan 26, 2023

Allegation investigated: Residents call bells are not being answered timely

Licensing Program Analyst (LPA) Sabrina Calzada and LPA Cassie Yang arrived at the facility unannounced to deliver findings to a complaint received on 7/19/22. LPA's met with Lacy Berry, Adminstrator and explained the purpose of the visit. Prior to initiating the complaint visit, LPA's completed the required COVID-19 protocols. LPA's wore a surgical or N95 mask and were screened by facility staff upon entering the facility. During the investigation, LPA Calzada interviewed the Administrator, Resident Care Coordinator (RCC) in July 2022, (4) staff, and (11) residents. LPA Calzada reviewed the facility Call Light Report provided for period July 1, 2022 - July 21, 2022 (12: 41 am). LPA received 93 of 126 pages of July 2022 Call Light report by email on 8/4/22. The results of the investigation are as follows: cont on 9099C(1).. Substantiated 9099C(1).Allegation: Residents call bells are not being answered timely. Complaint alleges it can take staff an hour or two to respond to call bells, or a resident’s cell phone when the front desk is called, and sometimes the staff don't respond at all. Call Light report for period July 1, 2022 -July 21, 2022 (12: 41 am) was reviewed. The report indicates the average response time is 21 minutes. While the report lists the average response time as 21.0 minutes for July 2022, there were multiple instances when the call response times were an hour or greater. Call response times were reviewed for resident (R1). The report shows response times varied during the month and records (3) instances where the response time was between one and two hours. Specifically, on these days/times: July 5, 2022 at 5:26 am- 118.5 minutes; July 14, 2022 at 6:57 am- 70 minutes; and July 20, 2022 at 8:52 pm- 79 minutes. The report also consistently shows at least one response time to be greater than one hour for other residents on each day of the period reviewed, from July 1- 21, 2022 with several days recording multiple instances of a response time of one to two hours or greater. R1 stated to LPA that call button response times are the longest during the evenings and during the NOC shift from 11 pm- 7 am and staff don't respond timely when she calls the front desk using her cell phone. Several (3) residents stated their call button doesn't work and (2) residents stated staff don't often answer when they call the front desk. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is issued on the 9099-D page. Exit interview. Copy of report and appeal rights provided. 9009A-C(1)... RCC stated on 7/28/22 that sometimes there are issues on the morning shift with showers not being given stating “we rely on (outside agency) and if they are a no-show, then the Med-Tech or RCC helps", and also “the "am" shift is heavy with showers". Administrator and (2) staff stated that a lot of residents do refuse a shower at times and staff will document when a resident refuses. Resident (R2) stated on 7/28/22 "most of the caregivers are from the agency- caregivers used to remind us of the shower day and time", but he now has to “find staff and ask for a shower”. One staff stated a lot of residents refuse a shower if they are tired or watching television with another caregiver stating that a lot of residents can refuse depending on the caregiver. Two additional staff stated that some residents are not given showers because they are not offered one by agency staff who often take long break periods. One resident who is scheduled for early morning showers on Wednesdays and Saturdays stated on 10/19/22 that he did not receive a shower that morning, but staff told him he could get a shower at 11:00 pm later that day. Another resident stated on 10/19/22 that she missed her shower this last Sunday and staff is on their phone during her shower and staff will shower residents in the middle of the night when it's “freezing cold, so residents will often refuse”. When asked if showers are given timely, another resident stated on 10/19/22 “it depends on the number of staff", commenting that she did not get a shower on Tuesday, and she "never refuses". Two additional residents interviewed on 10/19/22 indicated that sometimes no staff will come by to offer a shower so they don’t receive one with another resident stating she has to ask for a shower. Another resident interviewed on 10/19/22 indicated he is not sure if he receives two showers weekly with a different resident stating she has received only two showers since February 2022 but she received a shower last week. R1 was interviewed on 7/28/22 and stated she only received one shower in the last week due to staff not knowing how to use the “Sarah Stand”. Resident was interviewed again on 10/19/22 and she indicated she received two showers in the last week. Based on information obtained, LPA finds the allegation to be 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. cont on 9099A-C(2).. 9099A-C(2).. Allegation: Residents laundry is not being done timely. Complaint alleges that laundry is not being done due to the lack of staff. RCC stated on 7/28/22 that caregivers usually do laundry and it is done on all shifts, am, pm and NOC. RCC also stated she is not aware of laundry being done late; residents' laundry is washed once weekly, per the schedule, and if it’s missed, staff will try and do it the next shift or next day. Administrator stated on 7/28/22 “residents have a laundry day once per week, to match their shower day” and “CNA’s are doing a good job”. Administrator stated on 10/19/22 that she advises staff they need to finish any laundry started by the end of their shift. R1 stated on 7/28/22 "the only problem is clothes return with holes or stains" and confirmed she gets her own laundry back. July 2022 staffing schedules show that (3) to (4) caregivers were consistently scheduled on the “am” and “pm” shifts and (2) to (3) caregivers were consistently scheduled for the “NOC” shift. One staff stated on 7/28/22 “Yes, laundry is done late or mixed up with another resident's" and temp agency staff "is doing the laundry, but they need to finish the laundry and return it to the resident", explaining that clothes are "left in the washer or dryer" for the next shift. Another staff stated on 8/8/22 that it depends on the caregiver if laundry is completed during the shift and that staff from the temp agency will do laundry. Several other residents interviewed on 10/19/22 stated their laundry is not done timely, is returned wet and/or unfolded, not picked up on shower days, and has been lost or mixed-up with another resident’s laundry. One resident stated that only (2) clothes dryers are working, he has lost (5) pairs of pants, and his laundry is washed but it is not returned or folded timely. R1 stated to LPA on 10/19/22 that her laundry was done last night. During the same interview, LPA observed only clean laundry in R1's clean laundry bin and the dirty laundry bin to be empty. Based on information obtained, LPA finds the allegation to be 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. cont on 9099A-C(3).. 9099A-C(3)... Allegation: Resident missed medication. Complaint alleges that on 7/18/22, the staff did not give resident her after dinner medications. LPA reviewed the July 2022 MAR for resident (R1) and resident (R2). The MAR shows staff initialed that resident (R1) received (5) of (5) scheduled evening medications and (4) of (4) scheduled bedtime medications on 7/18/22. LPA reviewed all medications for R1 for July 2022 and all medications were initialed as being administered as ordered except for medication Lamictal 25 mg which was ordered to be given once by mouth every morning for (14) days, effective 4/12/22, and then twice a day. MAR is initialed that all dosages were administered as ordered in the morning; however, is not initialed on the following (6) days in July 2022: 7/2, 7/4, 7/8, 7/14, 7/20, and 7/26. Staffing schedule for July 2022 shows staff (S1) worked on 7/4/22 and staff (S2) worked on the remaining days where the MAR was not initialed. Prior Department interviews show S1 has worked at the facility as a Med-Tech for several years, and S2 stated to LPA on 7/28/22 that she is a “Med-Tech in training”. Since there were not consecutive days where the MAR was not initialed, It is likely that the omission on the MAR for the day S1 worked is due to an oversight, and the omissions on the days S2 worked may be due to S2 being a a Med-Tech in training at that time. Neither S1 and S2 were interviewed during the investigation specifically about these omissions on the MAR. Administrator stated after dinner medications are probably referring to PRN medications which are only given when requested, and it's possible the resident expected to administer PRN medications as if they were routine medications. R1 stated in an interview to LPA on 7/28/22 that she takes the medication, Lasix and gets 40 mg in the morning and that she isn’t sure she was administered this medication today, explaining it is a small white pill. MAR shows Lasix was administered on 7/28/22 in the morning. R1 also stated that the Resident Care Coordinator told her on Monday, 7/25/22, the medication refill hadn't come in, commenting she is not sure if other meds are missing. MAR for July 2022 shows an “x” was entered in place of staff initials on 7/25/22, designating the medication is “on hold”. LPA observed (2) scheduled medications, Wellbutrin 150 mg and Aspirin 81 mg, for R1 to have unclear markings with a circle on the MAR for 7/25/22 and 7/26/22 for morning and noon dosages, making it unclear if the medication was given. R2 stated on 7/28/22 that he may have missed medications if the doctor doesn’t refill the medication. MAR for July 2022 notes staff initials were entered for every dosage ordered except for Carbidopa- Levodopa 25-100 mg for the noon dosage; however, there are staff initials indicating the medication was administered for the pm and bedtime dosage on the same day, so the medication had not run out. cont on 9099A-C(4).... 9099A-C(4)..RCC stated on 7/28/22 that the facility is currently short staffed with Med-Techs, but she and the Administrator can cover and administer medications. Administrator stated on 10/19/22 she has not heard of any medications not being administered as ordered; however, facility staff cannot refill a PRN medication without the physician’s authorization. Two other staff interviewed on 10/19/22 stated they are not aware of any missed medications, and two residents interviewed on 10/19/22 indicated medications are not given on time if there is not enough staff with one resident stating his medications are "probably" given to him late. Based on information obtained, LPA finds the allegation to be 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. However, an Advisory Note is being issued to document that omissions were observed on the MAR, making it unclear if a medication was given as ordered. Allegation: Staff are not trained properly on how to assist resident. Complaint alleges that resident has equipment that helps her get up and she must instruct the staff on how to use it. Resident (R1) stated to LPA on 7/28/22 that her showers are scheduled on Tuesdays and Fridays and confirmed she received a shower two days ago, on Tuesday. R1 asserted that she uses the "Sarah Stand", pointing to a stand in her private bathroom, explaining that the "Sarah Stand" (or Sara Stedy) helps her to get up and get to her wheelchair. R1 confirmed that staff will take her to the shower room for a shower instead of showering her in her private bathroom. R1 continued to explain that she received only (1) shower last week because the temporary caregiver staff was "unsure of herself and how to transfer" R1 from her bed to the wheelchair, asserting "I told staff she needs to use the Sarah Stand", and Physical Therapy staff trained all facility staff in how to use a Sarah Stand. Resident Care Coordinator stated on 7/28/22 that as far as agency staff, “only the caregivers are trained" and the agency says staff is trained to work in SNF's and in Assisted Living both. Caregivers help with ADL's and "they seem able to do that". RCC indicated that each caregiver is given a resident list with notes and she (RCC) walks through the building at the start of the shift" and gives training for their shift which includes orienting to residents. cont on 9099A-C(5)... 9099A-C(5)..LPA asked Administrator on 7/28/22 what specific training agency staff has. Administrator stated "CNA's have CPR and First Aid” training. When asked if the facility staff gives agency staff additional training, Administrator stated “temp staff will go with one of the Walnut House Staff, and the RCC will give a guide to the temp staff, at the change-over meeting, highlighting the needs of the residents”. LPA followed up with an interview with R1 on 10/19/22. R1 stated that “now staff are using the "Sarah stand except for (1) Certified Nursing Assistant (CNA) who is still refusing to use the Sarah Stand". One staff stated temp staff need to be trained on the specific resident, stating "a lot of staffing from the agency will return a few times" and at staff cross-over meetings, staff will discuss each resident's care needs- and “agency staff need more training on how to work with the resident". R2 stated on 7/28/22 that agency staff need more training on showers. Based on information obtained, LPA finds the allegation to be 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. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Nov 17, 2022 · control 25-AS-20220719143307

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Dec 1, 2022

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on record review and interviews conducted, the Licensee did not ensure that staff responded timely to resident's (R1) request for assistance when the call button was used on 7/5/22, 7/14/22 and on 7/20/22, which posed a potential health and safety risk and/or personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Nov 17, 2022

Plan of correction: Licensee/Administrator agree to conduct staff traiining on reiterating the importance of resetting the call light button at the time care is provided. Training to be conducted also on communicating with team members about covering all calls, in elvery hall, if a caregiver is busy with another resident or on break, so the call be answered timely. Documentation to be submitted to CCLD by fax/email by 12/9/22.

Type of visit: Case Management - Deficiencies

**This report was amended on 11/17/22 only to obtain a signature from the facility on the 9099/9099C pages as it was inadvertently not obtained when the report was delivered on 10/19/22. There are no other changes.** Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced to continue a complaint investigation. LPA met with Lacy Berry, Administrator and explained the purpose of the visit. LPA later met with Veronica Sison, Resident Care Coordinator. Prior to initiating the complaint visit, LPA completed required COVID-19 protocols, and wore the following Personal Protective Equipment (PPE): surgical mask. Additionally, LPA was screened by facility staff upon entering the facility. While at the facility, interviewing several residents, LPA observed the following deficiencies: At approximately 10:00 am, at the start of interviewing resident (R1), LPA observed R1 to have poured cough syrup on her breakfast tray. R1 stated the medication was delivered to her for her to take, before she eats breakfast, due to stomach issues. LPA notified a Med-Tech (S1) that staff must watch residents take their medication as part of administering it. LPA observed R1 to take the cough syrup in the presence of S1. Additionally, LPA observed nasal spray to be sitting on R1's night stand, unsecured. At approximately 11:00 am, LPA observed resident (R2) to be sitting near the door to her room that was partially opened, while opening a small bottle of medication and pouring 2-3 tablets in her hand. LPA knocked on the door to request to interview resident. LPA observed resident put the tablets back in the bottle and place the bottle in the storage area of her walker next to her. At approximately 1:00 pm, LPA observed resident (R3) to be sitting in her room with the door open and to have a bottle of Glucose tablets (50) in her room on a table. R4 immediately took the bottle and placed it in a drawer on the other side of her room. LPA spoke to Administrator about it who confirmed the RCC removed the bottle from R3's room around 4:15 pm today. cont on 809C(1)... 809C(1)..At approximately 1:30 pm, LPA observed resident's (R4)'s room open and R4 to be sitting in his room, using oxygen. LPA observed multiple tanks in his room. R4 told LPA he uses an inhaler in the morning and another one in the evening and showed LPA he had both inhalers stored in an unlocked drawer. LPA observed a small bottle of Ibuprofen to also be in the drawer with the inhalers. LPA discussed the situation with Administrator who requested RCC remove the Ibuprofen immediately. R4 stated to LPA until recently he kept both inhalers on the top of his dresser and was asked by a NOC staff to put them in the drawer. Administrator provided a copy of a physician's order stating R4 is authorized to keep Tiotropium-Olodaterol (Stiolto Respimat) 2.5-2.5 mcg/actuation Inhl Mist in his room and agreed to arrange for him to get a lock box for R4 to keep the inhalers in. At approximately 3:40 pm, LPA and Administrator discussed medication with resident (R5) in his room and asked if he was storing any in his room LPA and Administrator observed R5 open a top drawer of his dresser and pick up a medication cup containing (5) tablets, (4) white tablets and (1) red tablet. Administrator immediately requested R5 give her the medication and explained that it has to be secured with all of the other medications. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is cited on the 809D page. Exit interview. Copy of appeal rights provided.the state’s words, verbatim · CDSS document, Oct 19, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Oct 21, 2022

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observation, LPA observed multiple unlocked medications in residents' rooms on 10/19/22 from 10::00 am- 3:40 pm, which poses an immediate health and safety risk to residents in care. RCC or Administrator promptly removed the unlocked medications.the state’s words, verbatim · CDSS document, Oct 19, 2022

Plan of correction: Administrator agreed to ensure resident (R4) gets a locked box so he can secure the inhalers. Administrator and RCC also spoke to the family members of R2 and R4 advising that residents cannot return to the faciltiy with any medications at all. Today, there was mandatory staff training, per the Stipulation, and the topic was Medication Management. Allen Flores Consulting Group to send a copy of the Power Point and attendees to CCLD by 10/21/22.

Allegation investigated: Staff did not provide a comfortable temperature for resident in care.

On 09/20/2022, Licensing Program Analyst (LPA) Jacob Williams arrived at the facility and met with Lacy Berry regarding a complaint investigation into the allegation listed above. LPA wore a surgical mask and was screened by facility upon entry. Facility staff wore masks while on the premises. During the investigation, the Department toured the facility and conducted interviews pertinent to the investigation. The results of the investigation are as follows: ** Report continued on 9099-C ** Unsubstantiated Allegation: Staff did not provide a comfortable temperature for resident in care. Six (6) residents were interviewed in R1's hallway on the western far-end of the facility. 4 of 6 residents do not report experiencing any high temperatures in their room. 2 of 6 residents report experiencing uncomfortably high temperatures in their rooms during recent heatwave. It is learned that repairman responded to the complaints of high temperatures in these two rooms and fixed the issue when he was alerted. Caregivers have also worked with the two residents during the heatwave to increase air flow through their rooms by opening window and the door to the hallway in order to create a draft and cool down temperatures. When staff were asked what they would do if a resident complained of uncomfortably hot temperatures, all stated they would either supply them a fan or open window/door to create a draft. Administrator stated if a resident asks to move to a cooler room, as long as there is an available room with the same cost as their current room then administrator is happy to relocate them. Based on observation and interviews conducted, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Sep 20, 2022 · control 25-AS-20220913162033

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced at the facility to conduct an unannounced quarterly on-site visit pursuant to a Stipulation and Waiver and Order adopted on 5/23/22. LPA met with Lacy Berry, Admin, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by staff and answers were documented in their visitor screening log. During today's inspection, LPA reviewed the "Compliance Binder" and observed it to be organized and to contain tab dividers for each requirement as set forth in in the Stipulation. LPA observed the weekly and monthly tasks to have been completed and up to date and quarterly staff training to have been conducted monthly from June -August 2022, and filed next to the specific training documentation. LPA observed a first quarterly audit was conducted on 6/3/2022 as well as an on-site visit on 7/26/2022. Administrator stated she has an upcoming training scheduled within the week. Semi-annual med-management training is not due until on/around November 2022. LPA observed large binder with the most current care plan, reviewed/updated monthly, for each resident as well as a separate charting binder. LPA observed Administrator place a copy of the Stipulation in the binder and re-post a copy at a conspicuous place at the facility. There are no citations issued on this report. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Aug 24, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced at the facility to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Lacy Berry, (Admin) and Veronica Sison, Resident Care Coordinator (RCC) and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by staff and answers were documented in their visitor screening log. The facility is licensed for (110) non-ambulatory residents and has a hospice waiver for (8).Currently there are (64) residents and (4) residents receiving hospice services. LPA and RCC toured the interior and exterior of the facility including the common areas, activity room, medication room, shower room, kitchen, food storage area, laundry area, (1) employee bathroom and outdoor enclosed patio area with seating and shade. Multiple residents' rooms had doors open and were observed from the hallway. LPA observed all areas to be clean, in good repair and odor-free. LPA observed locked sharps in the kitchen, locked toxins in the laundry area, and locked medications in the medication room. LPA observed (5) residents participating in various activities in the activity room and activity calendar posted. LPA observed various Covid posters throughout the facility. Facility to post 20-second hand-washing posters at each kitchen/bathroom sink. All doors have exit alarms. LPA observed sufficient 2+ day perishable and 7+day non-perishable food, ice machine to be clean and various cleaning schedules posted in the kitchen. Fire extinguisher was last serviced 12/9/2021. LPA observed other required postings posted including Resident Rights and House Rules. LPA and Administrator discussed vaccination status of residents and staff and scheduling an upcoming booster clinic at the facility. PPE supplies sufficient. cont on 809C.. 809C(1). LPA observed the inside temperature to be 75*F. Administrator was provided with a current copy of staff roster printed and will update as needed. LPA provided a box of sanitizers from the Regional Office supply during today's inspection. LPA requested an updated copy of LIC500, LIC308 and of the current liability insurance be provided to the CCLD by 8/31/22. There are no deficiencies issued during today's inspection. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Aug 24, 2022

Type of visit: Case Management - Legal/Non-compliance

An office meeting was held on 07/20/2022 at 10:30 AM on a Microsoft Teams Meeting video conferencing system review the stipulation adopted on 05/23/2022 and the next steps. This Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period. The following were in attendance: Regional Manager Alycia Berryman, Licensing Program Manager Maribeth Senty, Licensing Program Analysts Cassie Yang and Sabrina Calzada, Representatives of Solar Senior Living, LLC and Ciminocare and Josh Allen, from Allen Flores Consulting Group. Alycia Berryman discussed the purpose and elements of this type of meeting. The Stipulation was reviewed with Representatives, Administrators, and Licensees who expressed their understanding. Items discussed at the meeting included, but not limited to: Stipulation contents · Findings · Revocation of License- Stayed with Probation · Early Termination of Probation at Department’s discretion · Future Application for a license, registration, certification or approval · Completion of probation · Violation of Stipulation Term · Lacy Berry- Exclusion, stayed with probation · Lacy Berry- Revocation of Administrator’s certificate, stayed with probation · Lacy Berry: Terms of probation cont on 809C.. · Early Termination of probation at Department’s discretion · Lacy Berry: Future application for a license, registration, certification or approval · Lacy Berry: Completion of probation · Lacy Berry: Violation of stipulation term · Tolling of probationary period · Department’s Authority · Monitoring Fee · Waiver of Hearing Rights · Waiver of Appeal/Modification Rights · Waiver of Claims · Public Record · Signatures · Counterparts · Effective Date (5/23/22- 5/23/24) · No Oral modification · Representations regarding Corporate License The Licensees/Respondents/Representatives stated they would abide by the following: ꞏ Abide by the contents/terms of the Stipulation (submit all documents timely) ꞏ Operate the facility in strict compliance with the regulations and statutes governing the operation of a residential care facility for the elderly. CCLD will do the following: ꞏ Increase monitoring Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. A virtual exit interview was conducted, and a copy of this report was provided via email for a signature. Administrator agreed to return a signed copy to CCLD by COB 7/20/22.the state’s words, verbatim · CDSS document, Jul 20, 2022

Allegation investigated: Resident's requests for assistance are not responded to. Resident's clothing is not being laundered. Resident's showering needs not being met. Resident's administration of medications is being mismanaged.

On 6/15/22, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with clinical staff. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms.Upon arrival, completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened with temperature at the facility. LPA conducted records review and interviews. LPA interviewed R1 again today 6/15/22 LPA is unable to find and or meet the preponderance, per policy. R1 maintained that they are not filing a complaint, they only wish to have improved communication. R1 requests to have their Service plan updated with details that would better assist her to manage Unsubstantiated information and expectations regarding her medications, pain medications, shower and laundry times and when best to use her call button vs. phone to the front desk. R1 also requests assistance with a information management system. 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.the state’s words, verbatim · CDSS document, Jun 15, 2022 · control 25-AS-20220404130057

Allegation investigated: Resident rights violated regarding wheel chair use. Resident personal information posted in the dining room.

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 4/26/22 to deliver complaint findings. LPA met with Administrator and explained the purpose of the visit. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility. The department reviewed client/resident records and conducted extensive interviews. The department finds that the allegations cited above are substantiated. Report continued. Substantiated LPA Mknelly interviewed the facility Administrator and kitchen personnel as well as received a copy of the facility's "Cannot transfer/ Able to transfer" list that was posted in the dining area on 3/11/22. It was found that a policy was in place that required R1 to move from her wheelchair to a dining chair. In order to inform staff of who is to be transferred for meals, a list was posted thereby divulging personal private information about a resident to others. LPA informed Administrator and kitchen staff that both the required seating and the public list were both violations of personal rights. The list was removed to a place only viewable by staff and alternative seating arrangements were to be instituted by the facility. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. 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. Report reviewed with . Copy of this report and appeal rights provided. 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.the state’s words, verbatim · CDSS document, Apr 26, 2022 · control 25-AS-20220311100957

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: May 10, 2022

Additional Personal Rights of Residents in Privately Operated Facilities. (a)(2)To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not met as evidenced by interviews and observation that found personal information was posted in the dining area and was able to be seen by others. This posed a potential violation of resident rights.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: The situation has been corrected. Licensee will submit a statement of understanding of this requirement.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(6) · Plan of correction due date: May 10, 2022

Additional Personal Rights of Residents in Privately Operated Facilities. (a)(6) To make choices concerning their daily lives in the facility. This requirement was not met as R1 was told that she must transfer from her wheel chair at meal. This posed a potential violation of R1's personal rights.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: The situation has been corrected. Licensee will submit a statement of understanding of this requirement.

Allegation investigated: Neglect of basic care. Facility retained a resident who became bedridden and with

Licensing Program Analyst (LPA) Kevin Mknelly arrived unannounced to deliver complaint findings to the above allegations for a complaint received on 5/19/2021. LPA met with Lacy Berry, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 protocols. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured he applied hand sanitizer before entering the facility and wore the following Personal Protective Equipment (PPE): Surgical mask. During the course of the investigation, Licensing Program Analyst (LPA) Sabrina Calzada interviewed multiple facility personnel, including the Administrator, (3) caregivers/med-techs, (1) housekeeper, (2) family members of resident (R1), (1) friend who visited resident (R1), Ombudsman, and (3) home health care staff. LPA reviewed documentation pertaining to resident R1 including, but not limited to, initial assessment, care plans, Medication Administration Records (MAR), prescription faxes, charting notes, home health care plans and notes, and other documentation. Report continued... Substantiated Allegation: Neglect of basic care: Complaint alleges there is neglect of basic care for resident (R1) including the need for frequent brief changes, repositioning, grooming, bathing, linen changes, and adequate assistance with meals. Resident moved to the facility on/around June 27, 2017 and at that time was enrolled in a health plan that offered comprehensive home and community-based healthcare services to its participants. Resident’s initial assessment completed by the facility notes that resident needs assistance with bathing/showering, dressing, personal hygiene, uses a wheelchair and is able to ambulate by themselves, and wears hearing aids. R1’s home health care plan was reviewed on 7/2/2020 as part of a scheduled semi-annual reassessment and notes that resident needs to use pressure relieving devices, including a cushion for their wheelchair, be monitored for skin breakdown and needs to change positions frequently to maintain skin integrity and be free from skin breakdown. Care plan for R1 also states that due to urinary incontinence, resident is at high risk for skin breakdown and staff at RCFE will continue routine peri-care. Resident’s care plan was updated by the facility on 9/16/2020 following R1’s return from a skilled nursing facility. R1’s updated care plan notes resident is receiving hospice services, requires assistance with a wheelchair, mainly stays in bed, is a difficult transport, and requires a two-person assist. Additionally, the care plan documents that resident needs daily hair and skin care, cleaning of their glasses, and fingernail care, as needed, and requires full assistance with dressing and bathing. The care plan also notes that R1 is scheduled to receive a bed bath on Tuesdays and Fridays during the “pm” shift, has occasional to frequent incontinence and is high risk for skin breakdown. R1’s care plan was updated by the facility on 4/1/2021 and indicates that resident is receiving hospice services, uses a wheelchair occasionally, is scheduled for a bed bath twice weekly, toileted four times in a shift, requires assistance with oral care, and needs prompts at mealtime and staff to encourage fluids. Care notes were made by multiple nurses and other medical professionals, as follows: 5/4/2021- (12:20 pm) Acute visit- (S1-, LVN) Pressure wound to sacrum/wound care performed- Bed smelled of urine - diaper "soaked with urine and copious amount of blood". No drainage/odor noted during wound care; however, picture taken of "worsening of wound.” New wound orders to be written. 5/11/2021- (11:55 am) Wound Assessment- (S2- LVN) Unspecified pressure ulcer- nurse "reinforced previous education to RCFE staff/Med-Tech about the importance of turning patient every 2 hours to avoid pressure to area and to report any worsening of condition to home health. Staff/Med-Tech verbalized understanding". 5/12/2021- (2:15 am) (S3- LVN) wound assessment/care- "found wedge in closet, turned patient to right side and placed wedge per current orders. Educated med-tech to keep wedge on patient and turn patient every two hours even if patient moves, informed that patient has saturated depends and needs changing right away. Per med-tech, patient gets assistance in feeding and only eats a very small amount maybe 25% of meals. Administrator stated to LPA Mknelly that resident disliked the wedge and that pillows were used for repositioning. 5/13/2021- (9:20 am)- Acute visit- Sacral wound assessment and care- Patient was transported by gurney via outside transport. Patient appears emaciated. Patient presents with food around mouth, large stain covering the front of dress, and food, dirt and possibly leaves or salad in blankets. Feces or dirt present under patient’s fingernails. Hearing aid in patient’s left ear appears to be caked with old food and possible spinach leaf". Report continued... Nursing notes (S4-, RN) read ” Patient reporting a "medium" amount of pain in sacrum- 8/10 on Pain Assessment in Advanced Dementia (PAINAD) scale, and states pain is constant. Patient observed to have "grimacing, moaning, striking out" during wound assessment. Nurse Practitioner performed assessment of wound –appears to have an unstageable pressure injury to left sacral region”. 5/13/2021 (1:50 pm) – Nurse (S5- RN) called Walnut House Med-Tech (S6) who could not confirm how often resident is getting changed and repositioned but stated it should be every 2 hours. RN requested S6 speak to staff that it's critically important patient is kept clean, dry and repositioned at least every 2 hours to prevent further skin breakdown. S6 indicated full understanding and she would speak to staff immediately at shift change (1430). Resident’ s pain level could not assessed but resident wanted something for pain. Patient is in diaper with strong smell of urine. Patient is very thin woman lying to her R side... unable to distinguish if wound smells foul vs smell of strong urine. 5/13/2021 (4:35 pm) -RN, S5, attempted to contact facility Med-tech for follow up question regarding how often resident is receiving PRN Norco for pain management, as patient demonstrated moderate/severe pain while under care. Nurse’s notes say "called RCFE x2 and was not able to reach any staff both times" Mon, 5/17/2021- (11:30 am) – (S7- RN) Wound Assessment and care provided- Wound measured 6 cm x 3 cm x 1 cm- “Unstageable”, pain was assessed, and PRN supply of med was checked as well as MAR. Checked incontinence brief status. Home Health nurse S5 stated in an interview on 5/20/21 that their nurse found R1 “had a foul odor " and had not been bathed for a while and the nurse demanded that facility staff give her a bath. Tues, 5/18/2021- R1was visited by Ombudsman whose notes reflect resident to be “well groomed and clean, and her clothes and bedding were also clean” although her hearing aids were not in. Resident was transferred to a skilled nursing facility by home health. Care staff S8 stated on 6/23/2021 R1 had to be changed or turned every hour or two and resident “was prone to bed sores" and R1’s nails needed to be trimmed. An individual who regularly visited R1 stated she regularly heard R1 cry out “turn me, turn me”. A family member of resident stated that resident was “bathed every week or every other week” and did "maybe have some build up on her face". A care staff stated on 6/15/2021 “We all noticed she did decline after she tested Covid positive- she was harder to get up- it took 2 people to transfer her from her bed to the wheelchair, adding, “she always slept in her recliner- that was her routine- since January 2020 and we would toilet her and get her dressed for bed. She then stopped sleeping in the recliner when she left with Covid positive- it took 2 people to transfer her”. A nurse with home health stated in 5/20/2021, when resident returned from the hospital to the facility after recovering from COVID, she could get in her wheelchair but then sometime after that she could not, stating she "is bedridden now". Home health notes of 4/30/21 note, "Pt. bed bound." "Continue to reposition resident every 2 hours. Resident’s care plan was updated by the facility on 9/16/2020 following resident’s return from a skilled nursing facility and notes resident is receiving hospice services, requires assistance with a wheelchair, mainly stays in bed, is a difficult transport, and requires a two-person assist. Review of the Department records shows that the facility was issued a new license on 8/6/2018 permitting 110 non-ambulatory residents, 8 of which could be receiving hospice services. LPA Mknelly confirmed with Sacramento Metro Fire that when resident's become bedridden, CCL is to be informed. Metro Fire will then assess if the room occupied meets fire regulations. Complaint alleges facility has not requested refill of PRN pain medication since 2/16/21. MAR records reviewed show that resident had a prescription for 1 tablet, Norco 10/325 mg, twice daily, as needed for pain during the day, effective 2/13/2020. Facility provided documentation, dated 2/16/2021, showing the response received to a refill request for PRN Norco- 325 mg-5 mg (1 tablet every 6 hours): “This medication has been discontinued due to treatment change”. According to MAR documentation for the period reviewed, from January 2021- May 13, 2021, there were no doses of Norco administered to resident. Home health records regularly noted between February and May 2021 that R1 was not reporting or exhibiting pain. On 4/13/21, Home Health noted “last Norco on 4/8/21”. One staff stated on 6/23/2021 that resident “never asked” for medications, but only for coffee and would say "Help" and when she would go and attend to resident, resident didn't realize she asked for help and she “wouldn't say she wanted anything”. Another staff stated on 9/10/2021, "yes, she complained about pain, but she would spit it (meds) out" and that staff did inform the doctor, by fax, and asked if they would send a nurse out to evaluate resident. A family member of resident confirmed she was NOT ordering medication refills but the home health nurse would, stating “(R1) was not able to communicate about needing pain medications" and it wasn't the facility’s fault, explaining that resident "was not asking for help" due to not being able to communicate well. Resident’s home health company nurse stated that on 5/20/2021 that resident did not receive any pain medications since 2/16/2021 when the refill ran out and resident has been in pain since then, grimacing at times; yet home health notes contradict this statement. Home health notes dated 5/13/2021 (9:20 am) document ”Patient reporting a "medium" amount of pain in sacrum- 8/10 on Pain Assessment in Advanced Dementia (PAINAD) scale, and states pain is constant. Patient observed to have "grimacing, moaning, striking out" during wound assessment. Documentation reviewed shows a new prescription was issued on 5/14/2021 for PRN Norco 325 mg-7.5 mg, 1 tablet every 6 hours, for comfort care (total 21 tablets for a 7-day supply). MAR for May 2021 shows (1) tablet of Norco 325 mg -7.5 mg was administered on 5/14/2021 as a PRN medication (time is not noted on MAR). Release of Medications dated 5/18/2021 notes that 21 tablets of Hydrocodone 325 mg- 7.5 mg were released back to R1’s responsible person (error in documentation). It is therefore unsubstantiated whether the facility failed to refill pain medications for R1. LPA did advise Administrator of the need to maintain resident records for timely review by CCL, maintaining home health records, having PRN authorization letters for residents and maintaining resident medication orders on file. Allegation: Change in condition was not noted in care plan. Resident returned to the facility from skilled nursing, on 9/11/2020, after being sent out to the hospital emergency room on 8/15/2020, and being diagnosed with Covid-19. Interviews revealed that resident was unassisted at night before contracting Covid with one staff stating, “we would toilet her and get her dressed for bed. She then stopped sleeping in the recliner when she left with Covid positive- it took 2 people to transfer her”. Interviews further revealed that resident had declined due to contracting Covid-19 and upon returning to the facility, mainly stayed in bed, was a more difficult transfer, requiring 2-persons, and needed a bed bath. Resident’s care plan was updated to reflect these changes on 9/16/2020. Resident’s care plan was updated again on 4/1/2021 based on the date and facility staff initials on the document. These updates to resident’s care were noted on the same care plan that was previously dated and initialed on 11/9/2018. It appears there were several updates made on 4/1/2021 to resident’s care plan dated 11/9/2018, including: resident now requires occasional assistance with the wheelchair, a bed bath, instead of a shower with washing assistance, toileting 4 times per shift, assistance with oral care, instead of prompts and reminders. The care plan document dated and initialed on 4/1/2021, also notes that resident is “independent” with transfers, but on hospice, which is contrary to what home health notes from May 2021 showing resident to be non-ambulatory, bedridden and receiving assistance in feeding. Based on interviews conducted and documentation reviewed, LPA has determined the allegation to be unsubstantiated. LPA advised that care plans with signatures of resident /designee participation be maintained in all resident files. 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. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. 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. Report reviewed with . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 1, 2022 · control 25-AS-20210519103650

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: Apr 22, 2022

87464(d) Basic Services (d) … the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal ...This requirement is not met as evidenced by: Based on interviews and documentation reviewed, the Licensee did not ensure that resident’s (R1) care needs were met including hygiene, repositioning every 2 hours and changing briefs, resulting in pressure sore to worsen which posed an immediately health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 1, 2022

Plan of correction: The resident identified in this complaint is no longer at the facility. Licensee will present a detailed plan of identifying resident needs, staffing to be provided, documentation of condition changes and communication with health care providers with CCLD by POC date of 4/22/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87606(c) · Plan of correction due date: Apr 22, 2022

Care of Bedridden Residents - (c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). This requirement has not been met as evidenced by: Based on document review, the facility does not have an approved fire clearance for bedridden residents and the resident was not identified as Hospice which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 1, 2022

Plan of correction: Licensee will submit a statement of understanding of the requirement for when a fire clearance is needed and notification requirements to CCL if a resident becomes bedridden. Statement to be provided by POC date of 4/22/22.

Allegation investigated: Staff are not responding to residents alerts timely Staff does not follow the disaster plan as required

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on to deliver complaint findings. LPA met with and explained the purpose of the visit. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility. The department reviewed client/resident records and conducted extensive interviews. The department finds that the allegations cited above are substantiated. During the course of the investigation, LPA Sabrina Calzada requested the facility’s call alarm logs and was told by the Administrator that they did not have access to them. LPA Kevin Mknelly repeated the request in March 2022 and was provided call logs for June- July 2021. Substantiated LPA Mknelly review sample of call logs for June 1-4, 2021 and July 1-4/ 2021 found the following: June 1- 4 had a total of 52 calls recorded with a response time of greater than 20 minutes; July 1- 4 had a total of 54 calls recorded with a response time of greater than 20 minutes: Call log for 7/13/21 for R4 found that at 5:27:18 am, the resident’s call was made. The response time is recorded as 61.9 minutes. An indent report submitted on 7/17/21 of 7/13/21 notes that staff responded to R4 at approximately 6:30 am for shortness of breath secondary to respiratory condition which required emergency response and resulted in hospitalization. On 10/14/21, LPA Calzada interviewed three (3) residents, 2 of 3 reported wait times in excess of 1 hour. While interviewing R 2 , R2 noted that they had been waiting 20 minutes for incontinence care when LPA arrived. On 3/30/22, LPA Mknelly interviewed three (3) residents with recorded response times June 1-4/ 2021. Two (2) of the three (3) residents stated that long wait times have happened and continue to happen. A fourth resident was interviewed on 3/30/21 by LPA Mknelly regarding a resident report that they also experience long wait times. In the interview with R 3 , R3 stated that they regularly experience long wait times, they have reported that their button does not work. LPA and R3 tested the call button which was not in reach if R3 when LPA arrived. The button was pressed at 1:55 pm. Red light indicated a call was sent. No staff response at 2:40 pm. LPA spoke with a maintenance manager, Patrick Guevara, who acknowledged that the button should be tied to R3‘s bed and that he has checked the button several times and has ensured to works. LPA then went to the reception area where calls are monitored. Receptionist, Aylin Mendez, should LPA that no call was recorded for R 3. Receptionist recorded a repair request. Therefore, this allegation is substantiated. **This page contains Amended language** On January 29, 2021, the facility submitted an incident report for a power outage on January 27, 2021 at 2:00 am. Facility’s emergency and disaster plan states that “… Disaster Leader… will ensure residents are kept comfortable… will continuously communicate with licensing representatives…”. Reporting requirements are that the facility notify Community Care Licensing of a catastrophe within 24 hours. R1 reported that they informed their family/ representative of the outage the following day. Family representatives agreed with the statement. AccuWeather.com recorded the temperatures for 1/27/21 as 42- 52 degrees F., 1/28/21 as 45- 50 degrees F. Interviews found that the facility did not supply space heaters to be run by the facility generator until 1/28/21. Staff placed blankets on the window of R1’s room to reduce drafts. Residents reported cold foods were supplied to residents. Administrator stated facility did not lose capability to serve hot food and drinks. Therefore, facility failed to follow the disaster plan as required by not properly reporting to CCL, a resident family and ensuring residents were kept comfortable. Administrator stated to LPA Mknelly during this review that resident families were notified and residents kept comfortable, As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. 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. Report reviewed with Administrator. Copy of this report and appeal rights provided. Records reviews and statements indicated that staff were scheduled during the overnight hours. While there is a substantiated allegation for staff not always responding timely to resident calls, evidence did not indicate that the facility was unattended. The facility maintains cash resources for some residents. During the time of this complaint, it is acknowledged that when the Administrator was not present, resident funds were not available. However, LPA did not find an instance when residents requested funds and were denied access. The allegation that staff does not effectively communicate is undetermined. However, it is found that facility staff did not properly report the power outage of 1/27/21 to all family members and CCL. 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.the state’s words, verbatim · CDSS document, Apr 1, 2022 · control 25-AS-20210721115341

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Apr 4, 2022

Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met based on records and statements showing insufficient staffing to meet the needs of residents. On 7/13/21 this posed an immediate risk to Resident health.the state’s words, verbatim · CDSS document, Apr 1, 2022

Plan of correction: Licensee will monitor responding to log records and submit a detailed plan to insure staffing to meet the needs of residents. POC due monday 4/4/22

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: Apr 22, 2022

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports ...(2) Occurrences, such as ..., catastrophes ... which threaten the welfare, safety or health of residents...within 24 hours ... This requirement was not met based on records and statemets that the January 27/2021 power outage was not reported as required. This posed a potential risk to residents.the state’s words, verbatim · CDSS document, Apr 1, 2022

Plan of correction: Licensee will update their Emergency Plan to specify reporting requirements procedures. to CCL by the POC date of 4/22/22.

Allegation investigated: Residents' toileting needs not met

Licensing Program Analysts (LPA) Kevin Mknelly arrived unannounced to deliver complaint findings to the above allegations for a complaint received on 1/6/2021. LPA met with Lacy Berry, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured he applied hand sanitizer before entering the facility and wore the following Personal Protective Equipment (PPE): N-95 mask. During the course of the investigation, the Department reviewed documentation including, but not limited to, Medication Administration Record (MAR) for (3) residents for Dec 2020 and/or Jan 2021, photos (2) submitted to the Department on 1/6/2021, staffing schedule for January 2021, Night Activity Reports, and other documentation. The Department interviewed the Administrator, (7) staff, (7) residents, a family member of resident (R1) and attempted to interview (2) additional staff who were not available for an interview. Substantiated The results of the investigation are as follows: Complaint alleges that residents are defecating on their beds and are made to lay in their own feces, and that the bedding is not being changed. Interviews were conducted with residents and staff from May- September 2021. A resident who has incontinence was interviewed in May 2021 stated, "at night, is the worse response time". A housekeeper stated in May 2021 that housekeeping staff has been changing resident sheets, and If there is only (1) caregiver on shift, and she starts in room 1, then it could be (2) hours until the caregiver gets to the resident in room 65 due to the distance in the building. A Med- Tech stated in July 2021, when asked about residents being left in soiled bedding, “Yes, it has happened before -it's with the heavy wetter’s- usually the "am" saying they are too wet" and added that “NOC shift needs to pay more attention to the heavy wetter’s”. A caregiver stated in June 2021 that residents are checked every 2 hours and staff checks on incontinent residents more often, indicating that about 50% of residents are incontinent and they are also checked on when they press the button for assistance. This caregiver stated she feels staff are "pretty good about changing". during the "am" and 'pm" but is "not sure about the NOC" shift and stated sometimes when she arrives at 6:30 am, she sees that there is one resident that could have been seen twice during the night. Administrator stated in June 2021 that residents are not left in soiled bedding and staff completes a "Night Activity Report" every day that shows which residents have to be changed during the night. The Administrator stated in the same interview that "all residents are changed at night- staff knows the heavy wetter’s- there are (2) to (3) residents- every hour they go”. The “Night Activity Report” was provided for the period October 17-19, 2021 and documents hourly checks for every resident and is marked as follows: Awake (A), Bathroom (B), Diaper Change (DC), Sleeping (S) or Medicine (M). Additional documentation reviewed includes a list of residents who are incontinent, and a posted list for staff near the medication room indicating which residents (8) need to get up on the night (NOC) shift. Of the (8) residents that need to get up on the NOC shift, (2) residents, R2 and R3, are incontinent and were not toileted during the period reviewed. Specifically, R2 was not toileted on 10/17/21 & 10/19/21- and was observed to be awake at 5 am and at 6 am on each night; however, was diapered on 10/18/21 at 4:00 am. R3 was not toileted on 10/19/2021; however, was diapered at 12:00 am and 5:00 am on 10/17/2021 and at 11 pm, 4 am and 6 am on 10/18/2021. Additionally, resident R4, was not toileted on all three nights and resident R5 was not diapered on 10/18/2021 but was diapered on 10/17/2021 at 2:00 am and on 10/19/2021 at 2:00 am and at 6:00 am. Both R4 and R5 were noted as residents who needed to get up at night. Based on information obtained during the investigation, the Department finds the allegation to be SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Report reviewed copy of report and appeal rights provided. Complaint alleges that medications meant for residents are left out on tables, with glasses of water, and are not being given to the residents. The Department was provided with a photograph in January 2021 of what appears to be a small table or nightstand next to a resident’s bed with (2) Styrofoam cups and (6) disposable paper medication cups, containing (1) to (3) pills each. The photo also shows a pair of reading glasses next to one of the Styrofoam cups. Information obtained during the investigation revealed that the photo was taken from resident R1 room on/around January 2021. During an interview with resident R1 on 10/21/2021 in R1’s room, LPA Calzada observed an identical looking box, to that of the one in the photograph provided, with a purple side facing R1’s front door, and a black top, to be next to the air/heater unit and bed. Additionally, the top of the box observed in R1’s room had a piece of clear packing tape down the middle as well as a slightly tattered top corner, as shown in the photograph. R1, who does not have a diagnosis of Dementia, indicated that he has had the box in his room for about (3) years and "uses it as a piece of furniture". R1 indicated that he keeps one or two Styrofoam cups of water, usually, on the box, as he uses as a table. R1 was shown the photo and asked if he has ever observed medication cups to be in his room, as shown in the photo. R1 stated that he has never seen his medications look like the medications in the photo, and that he always takes his medications when they are administered to him. R1 stated in a follow up interview on 11/10/2021, “I have never refused and if I would, I would tell the Med-Tech". Interviews with (2) med-techs confirmed that the round, brown tablet pictured in the medication cups in the photo is the medication, Senna; however, neither staff was able to identify the round, white pill, also pictured. Review of R1’s Medication Administration Record (MAR) for December 2020 and January 2021 showed that R1 was scheduled to take (2) Senna 8.6 mg tablets and (1) Zetia 10 mg tablet, which can be either round or oblong, for bedtime medications. The MAR documentation reviewed for multiple months, including for December 2020 and January 2021, showed that neither medication was refused at any time by R1. R1 was asked if facility staff stay and watch him take his medications when they are administered, and R1 stated “"sometimes they watch and sometimes they just give it and go". A housekeeper stated in an interview that she has never seen medications left out as shown in the photograph and medications are consistently locked in the medication room. The Department finds that the box and medications in the photo provided match the box observed in R1’s room and the medications prescribed to R1; however, based on insufficient information provided as to a day/time the photo was taken, R1’s statements and MAR documentation reviewed, it cannot be established by a preponderance level of evidence that the medications shown in the photo were left out unsecured. Complaint alleges that certain residents are not being "lifted" or woken up so that they can be fed breakfast, and they are not always getting their meals. There were no specific resident names provided with the complaint. One caregiver stated that “there are a few residents that need help and the kitchen will get trays to those residents.” Residents interviewed, in May 2021, indicated that they are now going to the dining room for meals. Administrator stated by email on 10/20/2021, “yes, there were a few residents who were on hospice from January until around spring whom we fed while in bed and sat up to eat meals. We would get them out of bed earlier on when they were strong enough to do so. However, once their conditions progressed, we used their remotes to lift them to a sitting position in bed and fed them their meals and beverages. Because they were hospice and had fewer less appetites, we would only feed them as much as they desired to eat. “ Based on information obtained, the Department finds the allegation to be UNSUBSTANTIATED- a finding 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. Exit interview with administrator. Copy of report provided.the state’s words, verbatim · CDSS document, Feb 10, 2022 · control 27-AS-20210106155437

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Mar 10, 2022

Managed Incontinence- b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met Based on interviews conducted and documentation reviewed, the Licensee did not ensure that incontinent residents (R2 and R3) were toileted regularly, including throughout the night shift, which posed a potential health and safety risk to residents in care. Additionally, department LPA’s observed incontinent odors to be found on Hall 1, (room 57), on 10/21/2021 and on 11/10/2021.the state’s words, verbatim · CDSS document, Feb 10, 2022

Plan of correction: Licensee will review all current incontinent resident care plans, update as needed to comply with regulation (including development and review by the appropriately skilled profession) and submit residents' incontinence care plans to CCL by the POC date 3/10/21.

Type of visit: Case Management - Other

On 12/14/21, Licensing Program Analysts (LPAs) Kevin Mknelly and Cassie Yang met with Director/ Administrator, Lacy Berry. LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPAs are aware of a recent Covid Positive staff and one round of response testing completed with all results negative. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Masks. Additionally, LPA was screened by staff, upon entering the facility. The purpose of this inspection was to conduct a records review to tabulate identified resident care needs. LPAs conducted records reviews for residents R1- R12 and R13, 15 and 17. LPA will send Administrator a follow-up email and provided Administrator with a list of questions regarding the records reviewed. As a result of today’s inspection, no deficiencies were cited at this time. LPA(s) will return to continue the records review. LPA Mknelly reviewed this report with the Administrator and provided a copy.the state’s words, verbatim · CDSS document, Dec 14, 2021

Type of visit: Case Management - Other

On 12/9/21, Licensing Program Analyst (LPA) Kevin Mknelly arrived unannounced to conduct a case management inspection to follow up on recent concerns brought to their attention. LPA's Mknelly and Calzada and LTCO met with Lacy Berry, Administrator on 12/2/21 regarding and incident report of R1 leaving the building unassisted. LPA informed Administrator Berry that today's visit is a follow-up to that incident. and explained purpose of inspection. Prior to initiating today's inspection, LPA's completed required COVID-19 testing protocols, contacted the facility to confirm if there are any positive Covid-19 diagnoses, and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19. Additionally, LPA's were screened per Covid-19 precautionary measures upon entering the community. LPA's ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 or surgical Mask. The incident report submitted 11/19/21 stated that "around dinner time", R1 was observed in the community and refused dinner when cued. Statement by administrator that around 5:45pm when the caregiver brought the resident's tray to him, R1 was not in known locations and staff conducted a search of the building and grounds. Med tech, S1, stated to LPA that she located R1 when he was observed to be entering the building by the front door. The door was unlocked and the daytime door alarm sounded. S1 stated that she had not heard the door alarm when R1 had exited the building. LPA conducted an inspection of the facility's door alarms. The front door exit/entrance is the only door to have a daytime alarm that is only loud enough for the immediate area and a night time alarm that is like all others- it is louder and continuous until reset by staff with a code. At the time that R1 left the building, there were two caregivers and a med tech who were all occupied with resident care. The receptionist had left for the day. Title 22 regulation 87303 Maintenance and Operation (i)(1)(B) requires that (i) facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more ... shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met as Care staff did not hear the front door alarm when R1 exited the building. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. 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. Exit interview with Administrator. Report and appeal right provided.the state’s words, verbatim · CDSS document, Dec 9, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(i)(1)(B) · Plan of correction due date: Dec 10, 2021

Maintenance and Operation (i) facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more ... shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met based on records and interviews which found that on 11/18/21, R1 left the building unassisted and staff did not hear the front door alarm when R1 exited the building. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Dec 9, 2021

Plan of correction: Licensee agrees to utilize the alarm currently used for evening to be used at all times that staff are not present at or neear the front door. Licensee will submit a statement of the procedure for front door alarms to CCL by the POC date of 12/10/21. To be cleared by POC visit.

Type of visit: Case Management - Other

Licensing Program Analysts (LPA) Sabrina Calzada and Kevin Mknelly and Long Term Care Ombudsman (LTCO) arrived unannounced to conduct a case management inspection to follow up on recent concerns brought to their attention. LPA's and LTCO met with Lacy Berry, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA's completed required COVID-19 testing protocols, contacted the facility to confirm if there are any positive Covid-19 diagnoses, and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19. Additionally, LPA's were screened per Covid-19 precautionary measures upon entering the community. LPA's ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 or surgical Mask. During today's inspection, the following was discussed: staffing levels and recruitment efforts possible resident AWOL timely receipt of new medication order and in getting medication filled resident smoking area outside technical support by the Department technical support by the facility The following documentation was requested to be provided by 12/8/21: December staffing schedules (received 12/2/2021) October/November 2021 staffing time cards Personnel Report (LIC500)- current There are no deficiencies cited in this report from today's inspection. Exit interview with Administrator. Copy of report to be emailed to Administrator following the inspection.the state’s words, verbatim · CDSS document, Dec 2, 2021

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection. LPA met with Lacy Berry, Administrator, and explained the purpose of today's inspection is to discuss an amended page to a complaint report previously issued on 12/30/2020. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. LPA and Administrator discussed the amended 9099-D page that is part of complaint findings for complaint 27-AS-20200515160116. Appeal rights were provided via e-mail following the inspection. There are no deficiencies cited under this report. Exit interview. Copy of report provided via e-mail following the inspection to Administrator.the state’s words, verbatim · CDSS document, Nov 5, 2021

Allegation investigated: Facility is unsanitary Residents' bathing needs are not being met. Facility staff are not properly supervising residents. Staff left residents on soiled bedding

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to continue the investigation into a complaint recerived on 1/6/2021 and to deliver findings on the above allegations. LPA met with Lacy Berry, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before before entering the facility and wore the following Personal Protective Equipment (PPE): surgical mask. During the course of the investigation, LPA reviewed documentation including, but not limited to, Medication Administration Record (MAR) for Dec 2020 and Jan 2021, photos (2) submitted to the department on 1/6/2021, (3) Death reports (LIC624A) from 12/30/2020, and staffing schedule for January 2021 and shower documentation. LPA interviewed Administrator, (7) staff, (5) residents, a family member of resident (R1) and attempted to interview (2) additional staff who were not available for an interview. The results of the investigation are as follows: cont on 9099-C(1)... Unsubstantiated 9099-C (1)..Allegation: Facility is unsanitary. Allegation is floors are dirty and messes are left on the tables. Due to the department not conducting regular in-person inspections on/around January 2021, due to Covid-19 precautionary measures in place, LPA was unable to inspect the facility for cleanliness on 1/12/2021, when the complaint investigation was opened. On 5/20/2021, LPA observed different areas of the facility in person, including resident rooms, for cleanliness. LPA observed the entrance area to smell of cleaner/disinfectant, the living and front rooms with couches to appear clean and clutter free, the activities room and dining room to have clean floors and tables, and hallway carpets and carpet in residents’ rooms to appear clean and to have been recently vacuumed. On 6/23/2021, 7/21/2021, 9/10/2021 and on 10/14/2021, LPA observed the floors to be clean, recently vacuumed and the tables in the common areas to be clean and without messes. Administrator stated to LPA on 1/12/2021 that the facility did not currently have a maintenance staff person and the Maintenance Director splits his time at another facility and that housekeeping staff was doing the cleaning of the facility. Staff interview conducted in May 2021 revealed that for approximately eleven (11) months there was only (1) housekeeper until a second one was hired on/around April 2021. One staff stated that on/around January 2021, the floors and tables were dirty as residents were eating their meals and drinking coffee in their rooms through the end of February 2021 when they started eating in the dining room again and staff would find "yesterday's coffee" in their rooms. Another staff stated that everyone gets messy and sometimes the floor gets dirty but professional carpet cleaning is done in all resident rooms and in the lobby and that floors and tables are the first thing cleaned on the shift. A third staff stated that housekeepers do a good job in keeping the floors and tables clean, and if drinks and/or food are spilled on the tables in the common areas, it is cleaned promptly. Based on information received, LPA finds the above allegation to be UNSUBSTANTIATED. Allegation: Residents' bathing needs are not being met. One resident interviewed stated that the facility "is an old building and sometimes the shower breaks- they try very hard to get the showers in twice per week as scheduled". Two additional residents stated there have not been any problems with receiving showers. A caregiver staff stated staff will fill-out a paper if the resident refuses, and if they are short staffed, they will ask the resident if they can give the shower the next day. Another staff stated on 7/21/2021 that “showers are not skipped, generally, and caregivers have to report if showers are missed”. cont on 9099-C(2)... 9099-C(2)...Administrator stated that caregivers should note if a resident refuses the shower or if it is missed; if it is missed, it will be given the following morning and staff are diligent about ensuring showers are given twice weekly, as scheduled. LPA reviewed “Shower Refusal Documentation” requested on 1/12/2021 and was provided with documentation that (1) resident refused a shower on 12/29/2020, (2) residents on 12/31/2021, (1) resident on 1/12/2021 and (2) residents on 1/13/2021. There was no resident that had more than one shower refusal on the days reviewed. LPA and Resident Care Coordinator reviewed the weekly shower schedule and documentation completed following a shower being given on 10/18/2021. Of the (6) showers scheduled, documentation had been made by staff for (2) showers and LPA was advised that (1) resident received a shower from hospice services. For the remaining scheduled (3) showers, (2) residents stated they were offered a shower, with (1) resident refusing and (1) resident was not able to recall if she had received a shower yesterday. LPA finds the allegation to be UNSUBSTANTIATED. Allegation: Facility staff are not properly supervising residents. Complaint alleges that (2) residents were found dead because nobody had checked on them and another resident was left unsupervised “just lying there”. LPA reviewed a photo that was provided to the department showing resident (R1) to be on her knees and asleep with her head resting on her couch. LPA confirmed with (2) Med-Tech staff on 7/21/2021 and with the Administrator on 10/19/2021 that the resident in the photo provided to the department is resident (R1). One caregiver interviewed stated that there are a couple of residents that want to sleep on the couch and won't get up and there is "always someone around" to supervise residents. A Med-Tech staff confirmed they have never seen R1 sleep like that before and "no, it is not acceptable that we would leave her like that - we would put her in bed even though she liked to sleep on the couch”. Another staff stated that staff will let residents sleep and not wake them, even if they fall asleep in a chair or on the couch. A med-tech staff stated that R1 had a hard time moving around the table, so resident's daughter moved the table. Additionally, staff stated resident was "hard to turn for her age", has Dementia and has fallen asleep on the couch several times previously, as shown in the photo. Administrator stated that resident (R1) would often fall asleep in the position shown in the photo and “staff would try and wake her up and sit her back up and she would go back to laying on the couch”, stating “she loves the sofa”. Administrator indicated the large coffee table shown in the picture is not in R1’s room anymore and resident doesn’t sleep as much on the couch anymore since she is receiving hospice services and not as strong. cont on 9099-C(3)... 90099C(3)...The department is unable to determine from the photo alone how long R1 was sleeping on the couch, as shown in the photo, to establish that there was a lack of supervision by facility staff. Interview with one staff indicated that, on 12/31/2020, resident (R2) was discovered right away by the receptionist and her hands were still warm but was not sure who found resident (R3) whose family was with him when he died and had been with him all week. Another staff stated that both the death of R2 and R3 were “discovered right away” and resident (R4) was receiving hospice services and the nurse had recently indicated R4 had about one week to live. The same staff stated that resident R2 and R4’s room were near each others and R3’s room was also close by, and staff always knows right away if a resident passes, as with any change in condition, which are discussed at change-over meetings. LIC624’s submitted to the department note that R2 was observed to be unresponsive on 12/31/2020 at approximately 7:15 am and hospice was immediately contacted; the hospice company was immediately notified on/around 4:25 pm on 12/31/2020 for death of R3; and on 12/31/2020, R4 was observed to be unresponsive around 9:00 pm by the Shift Manager when entering resident’s room and the hospice was immediately notified. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED. Allegation: Staff left residents on soiled bedding. Complaint alleges bedding is not changed. A resident stated on/around May 2021 that her bed linens are changed weekly and cleaning is done regularly, but since there are only (2) housekeepers, occasionally something is missed. The same resident stated, "sometimes I heard but have never observed anyone to be laying in their bed and not changed timely". One staff stated that once there were (2) housekeepers, the housekeepers began changing the sheets, whereas, previously caregivers were in charge of changing sheets. Staff confirmed that it is possible a resident might have to wait for an extended period of time when there is only (1) caregiver working. Staff gave the example of “when a caregiver starts in room 1 and the resident in room 65 needs help, then it could be (2) hours until the caregiver gets to the resident, due to the distance in the building”. Additionally, if the facility is short staffed with caregivers, showers are not given, clothes and bedding are not washed, and the bedding sometimes can’t be changed because there are no clean sheets due to not enough staff to wash them. Staff stated the first thing caregivers do on their shift is change the bedding and housekeepers will also help. Additionally, the same staff indicated that staff will check on residents frequently and knows which residents need more frequent changing. cont on 9099-C(4)... 9099-C(4)...Another staff stated residents have been left in soiled bedding before-“it's with the heavy wetters- usually the "am" staff saying they are too wet" and asserted that the NOC shift needs to pay more attention to the heavy wetters. Administrator stated that residents are not left in soiled bedding. Based on information received, LPA finds the above allegation to be UNSUBSTANTIATED. Based on information obtained during the investigation, LPA finds the above (4) allegations to be UNSUBSTANTIATED- a finding 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. Exit interview with administrator. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 19, 2021 · control 27-AS-20210106155437

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection. LPA met with Karlisha, Med-Tech, initially, and explained purpose of inspection was to randomly speak to residents about living at the facility. Administrator was not present at the facility at the time of LPA's arrival. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. LPA began the inspection in the resident dining room and observed several residents to be finishing from eating lunch. LPA spoke to several residents who were in the dining room and then to additional residents who were awake in their rooms with the door open. LPA spoke to approximately (15) residents. LPA spoke briefly to Stephanie Paz, Resident Care Coordinator, who had to leave the facility during the inspection. There are no deficiencies being issued on this report. Exit interview with Med-Tech/Lead. Copy of report left at facility.the state’s words, verbatim · CDSS document, Oct 14, 2021

Allegation investigated: Staff is interfering with residents council meetings

***This report was amended on 7/28/2022 on the 9099-C page to include some additional information pertaining to the facility's interference with the Resident Council meeting held on 7/9/2021. The 9099-D page was also amended to remove unrelated information***. **This report is being amended on 8/4/2021 to indicate that on 7/21/2021 the department conducted a 10-day inspection to commence a new complaint investigation. Only the first sentence of the first paragraph, below, has been changed. There are no other changes being made to the report**. Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to attend a scheduled meeting and conduct 10-day on a complaint that was received also on 7/21/2021. LPA met with Lacy Berry, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn:surgical Mask. During today's inspection, LPA attended a scheduled meeting held at the facility from 11:00 am- 12:00 pm between (2) Ombudsman representatives, (3) residents who are on the Resident Council, (1) resident representative, and Administrator to discuss concerns brought to the Ombudsmans' attention by residents following a recent resident council meeting held on 7/9/2021. LPA also interviewd another staff member following the scheduled meeting regarding her role in resident council meetings. cont on 9099C.. Substantiated It was confirmed from today's scheduled meeting with the Ombudmsan that ballots were passed out to all residents on 6/18/2021 and were due by 7/7/2021. The ballot used was entitled "Nominations for Resident Council Meeting" and instructed residents to make their selection for each of the (4) officers listed and selections were to be written in as no names were pre-listed. The Administrator stated on 7/21/2021 that many residents expressed their reasons and discontent to her about the election not being valid and fair. The Ombudsman stated to the Administrator that if there are residents who are unhappy and/or have concerns with how the resident council is functioning, those residents can contact the Ombudsman's office for assistance and request the Ombudsman attend future resident council meetings. LPA and Ombudsman stressed that the facility role is to encourage and assist residents in the formation, operation and promotion of its council. Ombudsman provided Administrator with a copy of Rights of Resident Councils, based on Health and Safety Code §1569.157 and explained that any (2) residents can start a resident council and have the right to hold meetings without any facility staff attendance or interference. Resident (R1) who was nominated "President" stated that (13) ballot responses were received and when their follow up meeting was held on 7/9/2021, the Administrator, staff (S1) and a corporate staff member attended and disbanded the meeting, and eliminated the vote, saying that not enough residents had voted, and a new election would be needed. Residents (R1/R2) provided additional information on 10/19/2021 that at the start of the resident council meeting on 7/9/2021, the owner informed the residents that the Administrator was in charge of the meeting and staff (S1) was there to take notes. Residents (R1/R2) stated to LPA they had invited the Administrator and the owner, who indicated that his mother would probably like to attend the meeting, but they did not invite staff (S1) as they did not feel it was necessary to have her attend since she was not a manager or a person able to make changes at the facility. The Administrator stated to LPA on 10/19/2021 that both she and the owner had been invited to the meeting on 7/9/2021 by R1 but that staff (S1) attended and "took notes as a courtesy", as it had been done at prior resident council meetings. Staff (S1) stated to LPA on 7/21/2021 that corporate facility staff instructed her to be present at the resident council meeting, on 7/9/2021, to take meeting notes and because she and the Administrator were also attending. Staff (S1) further stated that multiple residents who attended the meeting were upset due to not being able to complete a ballot and not being comfortable with elected board members on the resident council. Additionally, it was learned through interviews that residents were instructed by the facility to print their first and last names on the ballots at the meeting on 7/9/2021. Based on information obtained, LPA finds the allegation "Staff is interfering with residents council meetings" to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview. Copy of report and appeal rights printed and provided.the state’s words, verbatim · CDSS document, Jul 21, 2021 · control 25-AS-20210721115341

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.157(g) · Plan of correction due date: Aug 4, 2021

§1569.157 Resident-oriented facility council (g) A facility shall not willfully interfere with the formation, maintenance, or promotion of a resident council, or its participation in the regulatory inspection process. For the purposes of this subdivision, willful interference shall include, but not be limited to, discrimination or retaliation in any way against an individual as a result of his or her participation in a resident council, refusal to publicize resident council meetings or provide appropriate space for either meetings or a bulletin board, or failure to respond to written requests by the resident council in a timely manner. This requirement is not met as evidenced by: Based on interviews conducted, the Licensee did not ensure that the facility did not willfully interfere as multiple facility staff attended a resident council meeting, held on 7/9/2021, and took control and adjourned the meeting and didn't allow the residents to lead their meeting, which posed a potential personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Jul 21, 2021

Plan of correction: Licensee/Administrator agree to read Health and Safety Code 1569.157 with facility staff and send a signed statement that the code is understood by staff. Documentation to be Faxed to CCLD by 8/4/2021.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff failed to safeguard resident's personal belongings.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete and deliver investigation findings to a complaint received by the department on 4/16/2021. LPA met with Lacy Berry, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, confirmed with the facility there are currently no positive Covid-19 diagnoses and completed a facility risk assessment. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical Mask. During the course of the investigation, LPA interviewed Administrator, Ombudsman, (1) caregiver, (1) med-tech, (1) housekeeper, (4) residents and resident's representative. LPA reviewed documentation including, but not limited to, charting notes regarding discussions of missing items, Resident Personal Property and Valuables (LIC621), receipts of clothing and other items purchased by facility and resident representative, Medication Administration Record (MAR), Unusual Incident/Injury Report (LIC624), and photographs provided by resident representative of empty closet and drawers. cont on 9099C.. Substantiated Resident (R1) who is the subject of the complaint moved to the facility on/around December 2018 and moved from the facility on/around April 2021. Resident was not available for an interview. Complaint alleged that much of resident's clothing, and her comforter, had gone missing from the time she moved to the facility, as well as resident's expensive shoes, glasses and partial tooth plate. Complaint alleged that resident was wearing other residents' clothing since hers had gone missing. . Interviews with (4) residents revealed the following: one resident stated she has lost a lot of her clothes, especially socks, even though her socks were marked with her initials; another resident indicated she has never lost any clothing, and she marks all of her clothes; a third resident stated she is not sure if any of her clothes or laundry have disappeared and a fourth resident stated none of his clothing or laundry has ever disappeared. LPA interviewed one staff who stated she is not aware that resident (R1) has lost any clothing or bedding items, but it's possible something could be misplaced if the staff returning the clean laundry to her room didn't pay enough attention. Two staff interviewed indicated that resident had a roommate prior to moving out and it's very possible that the resident's roommate's family may have inadvertently taken resident's (R1) belongings with them when they moved their family member out. Another staff confirmed that caregivers do the laundry and "we have a system- we put a whiteboard on the washer and dryer" showing who the clothing belongs to so it can be returned to the correct resident. Administrator stated in June 2021 that she purchased a "magnetic board" 4 months ago to write the resident's name on which sticks to the washer and dryer to identify who the clothing belongs to and confirmed that there have not been any clothes that have disappeared since the system was implemented. Administrator added "things do disappear in Assisted Living but we always stress finishing the laundry- whoever starts the load finishes it and to also communicate during changeover". Staff also will search for any missing items once reported. Resident's representative stated to LPA that he listed "clothes" on the LIC624 when resident moved to the facility but did not list each clothing item individually. Charting notes dated 4/7/2021 indicate that resident's representative stated he had not listed resident's clothing on the LIC621 when asked by the Administrator during a meeting with the Ombudsman present. LPA reviewed initial LIC621 provided by Administrator which shows that the only items as of 12/21/18 were a dresser and picture. On 1/5/2019 a toilet seat was added to the LIC621, and sheets .a bed spread were added on 10/15/2019. Administrator stated "we always do an inventory form- we ask the POA's to return it but some don't" and Administrator will complete the LIC621 if POA doesn't return it. cont on 9099C(2)... 9099(C)(2) Charting notes dated 4/7/2021 state that resident representative came to pick up resident for an appointment and contacted Administrator later in the day to report that some of resident's clothing and comforter were missing and the toilet seat riser in her bathroom did not belong to her. Notes state that Administrator confirmed with resident's caregiver that it was resident's laundry day and her clothes were in the washer. Additionally, the notes document that resident's comforter had been recently replaced when it was reported as missing, even though it was not listed on the LIC621. Notes further state that Administrator indicated that she would purchase some new clothing and replace the toilet seat riser, even though there was already one in resident's bathroom. Notes document that resident's representative stated he did not want Administrator to purchase resident any clothing, and he would be calling the Ombudsman. Receipts provided by the Administrator show that multiple clothing items and a comforter were purchased on 4/7/2021 (20:39 hours). Resident's representative provided (2) receipts showing clothing he had purchased on 4/14/2021 and on 4/24/2021, for resident. LPA reviewed a subsequent LIC621 completed on 4/7/2021 by the Administrator following the purchase of the items. Administrator stated that resident was familiar with her clothes and would wear her clothes only, and she would only hang up the clothes that belonged to resident. Charting notes dated 4/9/2021 note that Administrator received a call from a staff member stating that resident's representative was at the facility on the evening of 4/8/2021 to drop off "2 new shirts, 2 pairs of pants and a sweater for his mother" and he instructed staff to remove all of the items that had been purchased on 4/7/2021 from resident's room. Final meeting notes dated 4/15/2021 document a meeting held between the Administrator, resident's representative and the Ombudsman. It was discussed that new sneakers just purchased by resident's representative for resident needed to be added to the LIC621, and it was agreed that resident's representative would do resident's laundry himself and not bring any expensive items to the facility. It was agreed that a new toilet seat riser would be purchased by facility maintenance today as well. Receipt provided by the Administrator shows that a toilet seat riser was purchased on 4/15/2021 (10:12 am). Interview with resident's representative indicated that the first item to disappear was resident's expensive pair of shoes, on/around 2019, which were returned to resident's room, under her bed, 4 weeks later. Resident's representative stated that resident's clothing and the comforter were the next items to disappear, along with resident's prescription glasses and dentures. Administrator was not aware that resident's glasses or dentures had gone missing as they were not reported as missing and resident was always observed to be wearing both. cont on 9099C(3).. 9099C(3)... LPA and Administrator discussed Regulation 87218 and Health and Safety Code 1569.153. LPA confirmed that facility theft and loss policy is posted. Administrator stated that staff receives training during orientation of facility theft and loss policy. Administrator confirmed that the facility has not maintained a documented theft and loss record to document missing items, with a value of $25 or greater, and within 72 hours of being reported as missing. Licensee/Administrator did replace/attempt to replace resident's missing property, even though it was not documented on the LIC621; however, there was no theft and loss record maintained for LPA to review. The following additional concerns were brought to LPA's attention and investigated during the course of this investigation: 1) Facility was not giving resident regular showers- Interviews confirmed that resident was scheduled to receive two showers per week and resident would sometimes refuse a shower or didn't want to wash her hair, stating "she didn't feel good" . Another staff interview revealed resident may have refused a shower when it was changed to the "pm" shift, temporarily. Administrator stated that resident never refused showers and always allowed staff to wash her hair. 2) Facility was not washing resident's hair- Staff stated that sometimes resident didn't want her hair washed and resident liked to brush her own hair and staff would help her pin it up in a bun. 3) Facility did not stop Elliquis medication before resident went to her dental appointment. Resident representative and facility were unable to produce a physician's order that the medication should be stopped prior to a dental appointment. Ombudsman explained this to resident's representative also during the meeting held on 4/15/2021. LPA was not able to substantiate the (3) additional allegations. Based on information obtained, LPA finds the allegation: Staff failed to safeguard resident's personal belongings to be substantiated- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview. Copy of report and appeal rights printed and provided.the state’s words, verbatim · CDSS document, Jul 1, 2021 · control 25-AS-20210416095424

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a)(2)(A) · Plan of correction due date: Jul 16, 2021

87218 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. The licensee shall be presumed to have made reasonable efforts to safeguard resident property if there is clear and convincing evidence of efforts to meet each requirement specified in Section 1569.153. (A) A civil penalty shall be levied if the licensee or facility staff have not implemented the theft and loss program, or if the licensee has not shown clear and convincing evidence of its efforts to meet all of the requirements set forth in Section 1569.153. This requirement is not met as evidenced by: Based on record review and interviews conducted, the Licensee did not ensure that reasonable efforts were made to ensure that each requirement in Section 1569.153, specifically, that a theft and loss record for the last 12 months was made available for review, was met, in order to safeguard resident's property, which posed a potential personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2021

Plan of correction: LIcensee/Administrator agree to review Regulatilon 87218 in an In-Service training and documentation and follow up needed on any reported lost items. Documentation to be faxed to the department by 7/16/2021.

Allegation investigated: Facility failed to safeguard medications. Facility staff's lack of care and supervision resulted in resident being hospitalized. Facility staff’s lack of care and supervision contributed to resident’s death.

**This report was amended on 11/5/2021, on (1) 9099-D page only, so that (2) citations that were originally issued and subsequently dismissed, due to an incorrect regulation or health and safety code used, can be re-issued under the correct Title 22 Regulation. There were no other changes made to this original report issued on 12/30/2020. Licensing Program Analyst (LPA) Sabrina Calzada met with Administrator, Lacy Berry, on 11/5/2021 at the facility to review the amended 9099-D page and obtain signatures. ** Licensing Program Analyst (LPA) Sabrina Calzada conducted a tele-visit on 12/30/2020, due to Covid-19 precautionary measures in place, to deliver findings to a complaint received by the department on 5/15//2020. LPA met with Lacy Berry, Administrator, and explained purpose of today's tele-visit. During the course of the investigation, the department interviewed multiple facility staff members, attending Intensive Care Unit (ICU) physician and Toxicologist at the hospital, resident’s family members and others. The department also reviewed documentation including, but not limited to, resident’s medical records, Individual Plan of Care, narrative charting notes, fax correspondences with physicians, discharge paperwork for mental health services received, and facility medication records. The results of the investigation are as follows: Allegation: Facility failed to safeguard resident's medications. On or around 5/9/2020, resident's family members visited resident at the facility and brought resident 3 gift bags which contained gifts, food, Tylenol and Pepto Bismol. The bags were given to the front desk receptionist from the main door since only outside visiting was allowed per Covid-19 pre-cautionary measures. It is uncertain if the family told staff that there were medications in the bag. Family members stated that it was it was their expectation cont on 9099C(1).. Substantiated 9099C(1)..that packages are checked when dropped off, based on prior experiences. Family members indicated they recall staff (S1) stating that S1 would take the bags to R1’s room. S1 was interviewed and stated she only checked one of the bags, which had a black computer tablet and candy. Staff interviews were conducted which provided conflicting information. Some staff indicated that staff are responsible for checking gifts or asking the contents of the package and logging packages to ensure there are no hazardous items while some staff stated that packages are only checked if they are notified by family or suspect something hazardous in the package. Administrators and staff were unable to provide a written policy. Based on medical records reviewed, On 5/10/2020, R1 was admitted to the hospital with the initial complaint of a stroke, but after further testing, resident was diagnosed with liver failure. Resident's labs were drawn on 05/11/2020 which showed resident’s Tylenol to be at 265 microgram/ milliliters. The normal range for Tylenol is 0-30 microgram/milliliters. Based on interviews conducted, if R1’s labs would had been drawn at the time of arrival, it would have been significantly higher but since Tylenol metabolizes, the level was lower at the time the blood was drawn. Interviews indicated R1 had an acute ingestion of taking over 100 pills at one time. Based on toxicologist interviewed, it was confirmed that R1 had elevated Tylenol levels and explained that there were two possible scenarios that could have occurred; either R1 ingested multiple Tylenol pills over multiple days or R1 had a "massive overdose of Tylenol more than 24 hours ago". R1’s medication log was obtained from Walnut House for the month of May 2020. Tylenol was listed as a PRN medication, and the log was not marked on any days for the month of May. It is unclear how resident obtained a large quantity and had an overdose of Tylenol. Resident’s physician report dated 2/20/2019 documents that resident is “unable to administer own prescription medications and is unable to administer own PRN medication”. Additionally, PRN Medication Statement dated 4/19/2019 indicates that resident is “unable to determine his/her own need but is able to clearly communicate his/her symptoms for a non-prescription PRN medication(s)”. Based on information obtained, the department finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. cont on 9099C(2).. 9099C(2).. Allegation: Facility staff's lack of care and supervision resulted in resident being hospitalized. On 5/10/2020, an alternative emergency ambulance medical services was dispatched to Walnut House (see 809 dated 12/30/2020 for citation issued). It was reported that resident had an altered level of consciousness and was unable to follow basic commands. Resident appeared to have slurred speech and right facial dropping. Resident was transported to the hospital with an initial complaint of stroke. During the course of the hospitalization, resident was admitted to the intensive care unit (ICU) for acute toxic metabolic encephalopathy, decompensated liver failure secondary to Tylenol overdose, and disseminated intravascular coagulation (DIC) due to acute acetaminophen toxicity. Resident underwent multi organ failure and was placed on a mechanical ventilation. Resident’s physician’s report dated 2/20/2019 notes that the facility is responsible for managing and administering prescription medication and PRN medication. Resident’s medication log was reviewed for the month of May 2020. Tylenol was listed as a PRN medication, and the log was not marked on any days of the month of May. Based on information obtained, the department finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Facility staff’s lack of care and supervision contributed to resident’s death. Hospital medical records document that resident passed away on 6/8/2020 at 1210 hours. The immediate cause of death is listed as Cardiorespiratory arrest. Resident had renal failure and liver failure. Hypernatremia and Dementia were listed as other significant conditions that contributed to the death but not related to the cause of death. Hospital Toxicologist stated that resident’s cause of death was multi-organ failure and stated the overdose of Tylenol was the primary reason for the multi-organ failure. Toxicologist indicated that it was clear that resident had ingested a high amount of Tylenol and explained that there were two possible scenarios of how it occurred- either resident ingested multiple Tylenol pills over multiple days or resident had a “massive overdose of Tylenol more than 24 hours ago”. Toxicologist further stated that if an individual is seen within 80 hours of ingesting cont on 9099C(3).. 9099C(3).. a high amount of Tylenol, it would be easier to determine if they could be treated. By the time resident was seen, it was over 80 hours and it was difficult to predict if resident could be treated or if they was going to recover. Additionally, facility did not communicate to the Emergency Medical Technicians (EMT’s) that resident had a history of depression and suicide attempts by overdosing on medications, which affected the approach and timing of measurements taken once resident was admitted to the emergency room. Facility told the EMT's that resident was believed to have had a stroke. Sacramento Coroner Investigator ruled resident’s death as a suicide that was caused by ingesting a lethal amount of medication. Resident’s physician’s report dated 2/20/2019 notes that the facility is responsible for managing and administering prescription medication and PRN medication. Resident’s medication log was reviewed for the month of May 2020. Tylenol was listed as a PRN medication, and the log was not marked on any days of the month of May. Based on information obtained, the department finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following three (3) citations are being issued. Failure to comply with the Plan of Corrections by the noted due date may result in a penalty(ies) being assessed. 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. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 30, 2020 · control 27-AS-20200515160116

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(1)(B) · Plan of correction due date: Jan 8, 2021

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. This requirement is not met as evidenced by: Based on interviews conducted, the Licensee did not ensure that all packages dropped off on 5/9/2020 were screened prior to giving to resident (R1) to ensure there were no hazardous items inside, including Tylenol medication. Receptionist stated that the contents of only 1 of 3 bags, which was the bag without tissue paper, was viewed prior to giving to resident, which posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Dec 30, 2020

Plan of correction: Facility began logging all incoming packages on/around 5/16/2020 following incident, provided training at that time, and established a written procedure of checking all incoming packages, including gifts. Administrator stated all staff are currently following this protocol. Administrator agrees to provide documentation of training agenda/attendees and also submit a written policy to CCLD by 1/8/2021.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(e) · Plan of correction due date: Jan 8, 2021

§1569.312 Basic services requirements (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that staff was regularly “monitoring resident’s (R1) emotion, frustration or anxiety” resulting from resident’s diagnosis of depression and keeping a daily log to document resident’s needs and care, as noted on resident’s plan of care dated 10/31/2019, which posed an immediate health and safety risk to resident.the state’s words, verbatim · CDSS document, Dec 30, 2020

Plan of correction: Facility created a “Resident Change in Condition Form” on/around October 2020, to be used by both caregivers and Shift Managers and other staff when observing change(s) in condition in a resident. . Administrator agrees to conduct another staff training to remind staff to use the form, contact appropriate parties when a change in condition is observed, and update the care plan accordingly. Documentation of training agenda/attendees to be provided to CCLD by 1/8/2021.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Jan 8, 2021

87465 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: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that essential medical information, including resident's (R1) history of attempted suicide with medications, was conveyed to emergency medical services personnel, on 5/10/2020, which posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Dec 30, 2020

Plan of correction: Administrator agrees to conduct staff training on communicating client medical history and/or recent change in conditions, as noted on most recent care plan, to EMT. Administrator will discuss how to document essential medical information to be given to EMT's amd provide a form if created. Documenattion of training agenda/attendees to be provided to CCLD by fax by 1/8/2021.