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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700042
Report Date: 05/11/2023
Date Signed: 05/11/2023 02:40:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/06/2023 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230406152123
FACILITY NAME:SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
312700042
ADMINISTRATOR:MARK MORRISFACILITY TYPE:
740
ADDRESS:567 3RD STREETTELEPHONE:
(916) 409-4150
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:132CENSUS: DATE:
05/11/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Mark MorrisTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Resident lost severe weight while in care
Staff mismanaged resident’s medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday May 11, 2023 to complete and deliver findings to a complaint received on 4/6/2023. LPA met with Administrator Mark and explained purpose of visit. LPA interviewed the Administrator and facility staff including Marketing Director, Facility Nurses, Caregivers, med techs, R1’s Nurse Practitioner, wife and daughter. LPA reviewed resident’s file including physicians report, assessment, care plan, medication list, MARs, and PRN authorization form. The results of the investigation is as follows:

LPA reviewed R1’s assessment which stated that R1 required total assistance for meals. R1’s weight upon move-in on February 20, 2023 was 162 pounds. R1 visited his primary physician and weighed 148 pounds on 3/24/2023. Additionally, R1’s MAR noted that R1’s weight was recorded as 142 on 4/3/2023 by staff. R1’s primary physician was contacted on 2/24/2023 regarding R1’s agitation and confusion, there is no record of the physician being contacted regarding weight loss.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 59-AS-20230406152123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 312700042
VISIT DATE: 05/11/2023
NARRATIVE
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Upon move-in, R1 was prescribed three medications. One medication, Trazadone, had an order that was routine and as needed (PRN). On 3/24/2023, R1’s primary physician wrote a discontinue order for the Trazadone. At the facility, the routine Trazadone was discontinued, however the PRN order maintained. LPA clarified with R1’s primary physician who stated that her discontinue order was for both routine and PRN. Additionally, the PRN Trazadone order stated to give ½ tablet (25mg) to 1 tablet (50mg) by mouth at bedtime as needed for insomnia. R1’s MAR shows that the PRN Trazadone was given 8 times in March and once in April. Furthermore, R1’s PRN authorization form stated, as filled out by R1’s physician, that ‘My patient cannot determine his/her need for prescription and/or nonprescription PRN medication and cannot communicate his/her symptoms indicating a need for a nonprescription medication’. This form continues to state that ‘If your patient cannot determine his/her need for a medication or clearly communicate the symptoms for a nonprescription medication, then you, the physician, must be contacted before the PRN medication can be given’. There was no documentation or communication produced that shows the facility contacted the physician prior to giving the PRN medication to R1.

Based on the information detailed above, LPA finds that both these allegations are substantiated. A finding that the allegations are Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met.

Deficiencies cited on 9099-D. Appeal rights were printed and given.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 59-AS-20230406152123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 312700042
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2023
Section Cited
CCR
87466
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Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes. . . changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented
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Administrator to meet with management 5/12/2023, in the morning. Administrator to schedule training with med techs, nurses, and floor staff on 5/22/2023.
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 and brought to the attention of the resident's physician and the resident's responsible person, if any.This requirement was not met as evidenced by no communication between the facility and R1 regarding R1’s weight loss. This poses a direct threat to the health and safety of resident in care.
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Type A
05/12/2023
Section Cited
CCR
87465(d)(1)
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Incidental Medical and Dental Care
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, (1) Facility staff shall contact the resident's physician prior to each dose
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Administrator to assign facility staff to review all PRN authorization forms and ensure that med techs are following signed order. Facility to ensure complaince by 5/22/2023.
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This requirement was not met as evidenced by no communication with R1’s physician prior to dispensing the PRN medication to R1. This poses a direct threat to the health and safety of resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/06/2023 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230406152123

FACILITY NAME:SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
312700042
ADMINISTRATOR:MARK MORRISFACILITY TYPE:
740
ADDRESS:567 3RD STREETTELEPHONE:
(916) 409-4150
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:132CENSUS: DATE:
05/11/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Mark MorrisTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff neglected resident while in care
Staff failed to assist resident
Staff failed to meet the nutritional needs of the resident
Staff isolated resident while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday May 11, 2023 to complete and deliver findings to a complaint received on 4/6/2023. LPA met with Administrator Mark and explained purpose of visit. LPA interviewed the Administrator and facility staff including Marketing Director, Facility Nurses, Caregivers, med techs, R1’s Nurse Practitioner, wife and daughter. LPA reviewed resident’s file including physicians report, assessment, care plan, medication list, MARs, and PRN authorization form. The results of the investigation are as follows:

R1’s physicians report noted that R1 need to have food cut up and needs encouragement. Staff interviews revealed that R1 required prompting during mealtime. Staff acknowledged that they would sit with him during meals and assist with prompting/encouraging. Additionally, staff stated that they would try change of face, or different foods including ice cream, root beer, and later a prescribed nutritional shake.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 59-AS-20230406152123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 312700042
VISIT DATE: 05/11/2023
NARRATIVE
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R1’s chart notes that he would, at times, refuse medications. Staff interviewed stated that he would sometimes refuse assistance with activities of daily living (ADLs). Staff interviewed stated that R1 would become agitated and verbally combative. Staff interviewed stated that R1 was constantly walking in the hallways and common areas. All staff acknowledged that there were daily, repeated attempts during mealtimes, redirecting when exit seeking/wandering, and repeated attempts for ADLs.

Based on information obtained during the investigation, 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 evidence to prove that the alleged violation occurred,

Exit interview. A copy of this report was provided to the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 59-AS-20230406152123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 312700042
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2023
Section Cited
CCR
87465(e)(2)
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Incidental Medical and Dental Care
(e) For every prescription and nonprescription PRN medication . . . physician's order and the label shall contain at least all of the following information (2) The exact dosage.This requirement was not met as evidenced by
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Administrator to submit plan by POC due date. Administrator to assigned staff to reveiw all MARS and ensure prescription label complaince by 5/22/2023.
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R1’s PRN medication stating to take ½ tablet (25mg) to 1 tablet (50mg) by mouth as needed for insomnia. This poses a direct threat to the health and safety of resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6