312700042-12-18-2024-59-AS-KHOS-DCGHYV-20241231053723

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700042
Report Date: 12/18/2024
Date Signed: 12/18/2024 01:23:30 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/17/2024 and conducted by Evaluator Graham Gunby

COMPLAINT CONTROL NUMBER: 59-AS-20240117154538

FACILITY NAME:	SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	312700042
ADMINISTRATOR:	MARK MORRIS		FACILITY TYPE:	740
ADDRESS:	567 3RD STREET		TELEPHONE:	(916) 409-4150
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY:	132	CENSUS: 64	DATE:	12/18/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Executive Director - Megan Gallagher		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff failed to seek medical attention for a UTI and dehydration.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Graham Gunby and Cheyenne Ratajczak arrived unannounced on 12/18/2024 to complete and deliver findings to a complaint received on 1/17/2024. LPAs met with Executive Director, Megan Gallagher and explained the purpose of the visit.

Throughout the course of the investigation, the department conducted interviews and record reviews.

Please continue to LIC9099C..

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Graham Gunby	TELEPHONE: (916) 827-6870
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240117154538

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 312700042
	VISIT DATE: 12/18/2024

NARRATIVE

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Allegation: Staff failed to seek medical attention for a UTI and dehydration. Substantiated
Staff reported R1 had changes in condition beginning in November 2023. They observed R1’s urine was dark in color and had an odor consistent with a urinary tract infection (UTI). Medical records show R1 was seen at the emergency room on 11/17/2023 for a chief complaint of lethargy. However, medical records show not show a urinalysis test was conducted or that they were ever treated for a UTI. Medical records from this visit show R1 was assessed for behavioral issues and their medications were adjusted. On 12/18/2023, staff began noticing a decline in R1’s condition which included changes in weakness and mobility. Staff contacted R1’s family recommending R1 be places on hospice care. The file review records indicate R1’s primary care physician was not contacted regarding R1’s signs of weakness until 12/24/2023. On 12/24/2023, a fax correspondence was sent to R1’s primary care physician indicating R1 was lethargic, sedentary, and no longer able to feed themselves. The physician did not acknowledge receipt of the correspondence. Multiple staff considered R1’s changes in condition to be drastic and warranted her being sent out to the hospital on 12/24/2023. Staff reported R1 was sent out to the hospital on 12/24/2023. However, medical records support R1 was not sent out to the hospital until 12/25/2023 at approximately 1600 hours.

As a result of this investigation, 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.

Exit interview conducted. A copy of this report was left with the facility.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Graham Gunby	TELEPHONE: (916) 827-6870
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240117154538

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 312700042
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/19/2024 Section Cited CCR 87466	1 2 3 4 5 6 7	The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.	1 2 3 4 5 6 7	Licensee will complete a statement of understanding for regulation 87466. Licensee will also show proof for a planned trainning with staff. Licensee will email to LPA by POC due date, 12/19/2024.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by:Based on interviews conducted and records reviewed, facility staff observed R1’s health declining on 12/18/2024. Although facility staff reached out to R1’s responsible party, facility staff did not reach out to R1’s primary physician until 12/24/2024 resulting in a delay in R1 obtaining proper medical care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Graham Gunby	TELEPHONE: (916) 827-6870
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/17/2024 and conducted by Evaluator Graham Gunby

COMPLAINT CONTROL NUMBER: 59-AS-20240117154538

FACILITY NAME:	SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	312700042
ADMINISTRATOR:	MARK MORRIS		FACILITY TYPE:	740
ADDRESS:	567 3RD STREET		TELEPHONE:	(916) 409-4150
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY:	132	CENSUS: 64	DATE:	12/18/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Executive Director - Megan Gallagher		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Neglect resulted in resident's death.
Resident developed a UTI and became dehydrated due to inadequate care by staff.
Staff did not ensure that resident's room was sanitary.
Staff do not provide services to resident as promised.
Staff did not ensure that resident's hygiene needs were met while in care.
Staff handled resident in a rough manner, causing injury to resident.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Graham Gunby	TELEPHONE: (916) 827-6870
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

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 7

Control Number 59-AS-20240117154538

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 312700042
	VISIT DATE: 12/18/2024

NARRATIVE

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Allegation: Neglect resulted in resident's death. Unsubstantiated
On 12/25/2023, R1 was admitted to the hospital after exhibiting signs of shortness of breath and being unresponsive. R1 was discharged from the hospital on 12/28/2023 and returned to Summerset with a diagnosis of severe sepsis with acute organ dysfunction and urinary tract infraction (UTI). R1 was placed on hospice care on 12/28/2023 and passed away on 1/9/2024. R1’s death certificate lists cause of death as cardiac arrest and pneumonia. Other significant conditions contributing to their death were pulmonary embolism and severe dementia. Based on the information obtained, there is insufficient evidence that facility staff neglected R1 resulting in R1’s death.

Allegation: Resident developed a UTI and became dehydrated due to inadequate care by staff. Unsubstantiated
R1’s medical records documented that whenR1 arrived at the hospital on 12/25/2023, they tested positive for a urinary tract infection (UTI) and had signs of dehydration. Staff reported R1 consistently received assistance with toileting and brief changes in a timely manner. Staff also reported R1 consumed and appropriate amount of liquids and did not show any signs of dehydration. It is unclear if R1 had a history of sustaining frequent UTIs and required special measures. Interviews with residents documented staff meet resident’s needs. Based on the information provided, although R1 was diagnosed with a UTI and dehydration, there is insufficient information that staff provided inadequate care.

Allegation: Staff did not ensure that resident's room was sanitary. Unsubstantiated
Staff interviews revealed that R1 would often have a bowel movement not in the bathroom. Interviews detailed how R1 would the try to hide the BM. Notes detail R1 having a bowel movement on the wall and then screaming at staff when being redirected. Staff stated that R1’s room was generally clean and well kept. Staff interviews also acknowledged that R1 would frequently take all the clothes out of their closet and drawers, causing staff to have to frequently have organize and put the room back together. Based on the information provided, there is insufficient information that staff did not ensure resident’s room was kept sanitary.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Graham Gunby	TELEPHONE: (916) 827-6870
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 59-AS-20240117154538

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 312700042
	VISIT DATE: 12/18/2024

NARRATIVE

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Allegations: Staff do not provide services to resident as promised. Staff did not ensure that resident's hygiene needs were met while in care. Unsubstantiated
LPA interviewed staff regarding the allegations. Interviews stated that R1 was, at time, combative and resistant to care. Staff stated that they would ask R1 multiple times to assist with showering and would try a change of face. LPA reviewed resident notes which detail R1’s combative behavior to care including: ‘attacking’ hospice shower aid and becoming combative with staff. LPA reviewed doctor orders which show an increase in R1’s medications to assist with behaviors. Based on the information provided, staff were documenting when staff were unable to meet R1’s needs.

Allegation: Staff handled resident in a rough manner, causing injury to resident. Unsubstantiated
LPA reviewed resident notes which detail ongoing combative and aggressive behavior by R1. R1 had a history of being aggressive with staff and other residents. Additionally, notes detail R1 ‘not letting go’ of another resident, grabbing resident’s hair from the back of their head, and screaming. LPA did not identify any incident which R1 had a skin tear due to staff. LPA did not review any documentation regarding R1 having a skin tear or doctor notification of a skin tear. Additionally, facility did not submit an incident report or SOC341 to the department regarding a skin tear R1 sustained caused by staff. Staff interviews indicated that staff did not observe a skin tear on R1.

Based on this information, these allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated.

Exit interview conducted. A copy of this report was left with the facility.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Graham Gunby	TELEPHONE: (916) 827-6870
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

LIC9099 (FAS) - (06/04)

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