347003994-9-23-2020-27-AS-MSEY-BTSMV2-20200925095557

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003994
Report Date: 09/23/2020
Date Signed: 09/23/2020 09:32:25 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/12/2020 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200512144713

FACILITY NAME:	AEGIS ASSISTED LIVING OF CARMICHAEL		FACILITY NUMBER:	347003994
ADMINISTRATOR:	CHUCK SCHURINGA		FACILITY TYPE:	740
ADDRESS:	4050 WALNUT AVE		TELEPHONE:	(916) 972-1313
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	90	CENSUS: 63	DATE:	09/23/2020
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Chuck Schuringa, Executive Director		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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Staff did not follow the resident's care plan
Staff is not following physicians order's for monitoring resident's blood sugar

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada contacted facility by phone to deliver findings to a complaint the department received on 5/12/20. Findings are being delivered via phone due to Covid-19 precautionary measures in place. LPA spoke to Chuck Schuringa, Administrator, and explained purpose of call.

During the course of the investigation, LPA interviewed Administrator, Regional Health Services Director (HSD), Assisted Living Care Director (ALCD), Licensed Vocational Nurse (LVN), Med-Managers (2), and Maintenance Director. LPA reviewed documentation including, but not limited to, resident's (R1) physician's report, care plans (2), narrative charting notes, Medication Administration Record (MAR) for Feb- April, 2020 and Power of Attorney (POA) for Health Care.

The results of the investigation are as follows:

Allegation: Staff did not follow the resident's care plan. (The allegation references four specific areas, as follows):

1) Complaint states staff was not monitoring if resident ate food or not, and staff just left food in room. Multiple interviews confirmed that resident was a "picky eater" and often wouldn’t eat much in dining room during Pre-Covid and needed encouragement from staff to eat. Additionally, interviews revealed that resident would "often not finish" meals and resident would also bring food from the dining room and give to resident's dog. LVN stated that resident was served a different food choice if resident didn't want the designated menu item and that staff does not monitor residents' meals but monitors residents' blood sugar checks.

cont on 9099C(1)...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2020

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 5

Control Number 27-AS-20200512144713

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: AEGIS ASSISTED LIVING OF CARMICHAEL	FACILITY NUMBER: 347003994
	VISIT DATE: 09/23/2020

NARRATIVE

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9099C(1)...HSD stated "resident didn't eat as well when Covid-19 started, but resident would always snack and the med-techs and nurses would always go and check on resident". Charting notes dated 3/18/20, read “resident noted to eat very little during meal times” and that resident was encouraged and talked to "to at least have small frequent feedings and eat snacks if resident cannot eat regular meals." Additionally, these notes state that "care staff was requested to encourage resident to eat". Care plan dated 1/15/20 notes that staff will provide reminders and follow up to ensure resident attends meals. LVN stated there were many conversations during blood sugar checks with LVN and resident about ensuring resident ate throughout the day. MAR records show blood sugar checks were monitored and if the readings were low, orange juice was given to resident multiple times from 3/19/20- 4/7/20. Based on information obtained, it could not be determined that staff did not monitor resident's food intake at all.

2) Complaint states facility was supposed to have the resident drink a shake if resident did not eat the food. LVN stated when the Glucerna drinks were prescribed, resident would often not drink them, and staff would find one in resident's refrigerator in resident's room, 1/2 drank or just open, stating "resident never requested the shake but staff would encourage resident to drink it." HSD stated that resident drank Glucerna, which was a PRN, and if resident had some in resident's room, a third of the time we would offer it to resident with snacks as a supplement, in small frequent feedings, in between meals, as resident couldn't finish the whole Glucerna at one time. One Med-Manager stated that if resident wasn’t eating, staff would call the medication room and ask for a Glucerna, and two Med-Managers stated that Glucerna shakes were offered to resident a few times per week and sometimes staff would make a shake with the Glucerna and ice-cream and "even then the resident didn't drink a lot of it".

cont on 9099C(2)....

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 27-AS-20200512144713

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: AEGIS ASSISTED LIVING OF CARMICHAEL	FACILITY NUMBER: 347003994
	VISIT DATE: 09/23/2020

NARRATIVE

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9099C(2)..Review of MAR documentation notes that resident's physician order for Glucerna, dated 11/2/18, was listed as a PRN to be offered as a meal replacement for dinner. ALCD stated that it was not documented on the MAR if a caregiver offered Glucerna, but would be documented if offered by a Med-Manager. April MAR shows that on 4/4/2020, a Glucerna was given to resident at 5:00 pm. Resident's family member stated that the physician's order changed to a scheduled order, to be offered at every meal if the blood sugar drops. Resident narrative charting notes dated 4/8/20 confirm that a new order was received to give 1 bottle (296ml) Glucerna with dinner and also note that resident moved out on that same day. Based on information obtained, it could not be determined that a shake was not offered when resident was observed to not be eating her meals.

3) Complaint states that the facility will provide stand by assistance with showers for the resident and that the resident had not been showered for days on 4/8/20. Care plan dated 1/15/20 notes that staff assists resident with showering/bathing needs, 2 showers/week. ALCD indicated that resident was scheduled for showers on Tuesdays and Saturdays, during "pm" shift, and confirmed that resident received stand by assistance with showers. ALCD stated that sometimes resident did refuse to take a shower, but staff would try again later that day or the next day. LVN stated LVN was not aware of anytime resident was refusing showers. Based on information obtained, it could not be established that resident was not being offered or given showers as scheduled.

4) Complaint states that facility was not providing dog bathroom reminders, every 3 hours, as being charged per care plan. One Med-Manager stated that "all staff would provide bathroom reminders for the dog to the resident and the dog would only go outside with the resident" . Another Med-Manager stated "All care managers always gave resident bathroom reminders. In the beginning, resident was good about taking the dog out, but later on resident started forgetting to". LVN stated "The dog would often urinate in the elevator, hallway, and room because resident liked to sleep in, making the dog go when she needed to go and where she could go", asserting "It is resident’s responsibility to take the dog out for a walk." Maintenance Director stated that resident would feed the dog but would not take the dog out, even with reminders, due to resident's Dementia worsening.
cont on 9099C(3)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 27-AS-20200512144713

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: AEGIS ASSISTED LIVING OF CARMICHAEL	FACILITY NUMBER: 347003994
	VISIT DATE: 09/23/2020

NARRATIVE

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9099C(3)...Maintenance Director indicated that he was giving resident reminders, along with caregivers, and resident's room was cleaned weekly, as needed, and as requested by the family. Interviews also revealed that resident's family was aware of the dog defecating/urinating inside on a regular basis. ALCD stated that facility staff was providing more pet service than what was being charged to resident and confirmed that three daily bathroom reminders would be 60 points assessed. ALCD added that staff was providing bathroom reminders two times a day, in addition to giving the dog medication and cleaning up waste, and staff also took the dog outside when resident temporarily left the building. Resident’s care plan, dated 1/15/20, notes that resident requires assistance (walking, feeding, cleaning) with pet care 1x/day for total of 22 points, which was increased on 10/23/19 by 19 points, for reasons of picking up waste/giving medicine and notes this assistance is needed 2x/daily. Interviews confirmed that Med-Managers were giving the dog eye drops and maintenance staff was cleaning up during day time work hours and Care staff/Med-Managers would clean up after 5 pm. Based on information obtained, it could not be established that resident was paying for bathroom reminders or dog assistance that was not received.

Allegation: Staff is not following physicians orders for monitoring resident's blood sugar. Complaint alleges that the resident had an order for the nurse to check the resident's blood sugar four times a day, but the 4th blood sugar check after dinner was discontinued, and the Dr. did not approve this nor did the facility notify the family they were only checking the blood sugar three times a day. Care plans dated 10/23/19 and 1/25/20 note that blood glucose monitoring is done 2-4 times/day and “licensed nurse to assist with blood sugar checks before breakfast, lunch and dinner and record in ALMSA and a Med Manager will assist with blood sugar checks at bedtime, and will record results in ALMSA Resident is able to perform the finger stick on her own". LPA reviewed MAR, ALMSA and blood sugar meter documentation from 3/15/20- 4/3/20 and noted it to be consistent with physician orders. Administrator stated that the facility "followed the protocol on blood sugar checks and the 10:00 pm check was stopped because the nurse was concerned about waking the resident up at 10:00 pm and that it was not good to wake her up and the nurse was not concerned about the blood sugar levels at 10:00 pm as much as during the day".
cont on 9099C(4)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2020

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20200512144713

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: AEGIS ASSISTED LIVING OF CARMICHAEL	FACILITY NUMBER: 347003994
	VISIT DATE: 09/23/2020

NARRATIVE

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9099C(4). HSD stated "We dropped the 4th blood sugar check only for a few days after I reviewed if it was necessary to have the 4th check daily, based on resident's vital signs and parameters. I requested the doctor approve blood sugar checks for three times per day on March 25, 2020 because resident had a lot of pricking with testing blood sugar four times per day and also, we had to wake resident up and disturb resident's sleep". LVN stated that resident's blood sugar decreased towards dinner but went up after resident ate dinner and the 4th blood sugar check "seemed to be unnecessary". Narrative notes dated 3/26/20 note that resident's physician acknowledged the blood sugar readings and medication list sent by facility and a new order was received to decrease blood sugar monitoring to three times per day. Narrative notes dated 3/30/20, show that blood sugar monitoring was reinstated at bedtime, per family request, and the physician was to send new orders. MAR, ALMSA and blood sugar meter records all reflect that the 4th blood sugar check was stopped on 3/26/20 and reinstated on 3/30/20, immediately following request by family.

LPA reviewed POA Health Care documentation where resident authorizes family member(s) to make health care decisions if resident becomes incapable of giving informed consent; however, it could not be established that the POA Health Care had medical decision making power as there was not a letter from resident’s physician available, dated during the time period reviewed, stating that resident is unable to make medical decisions; therefore, the facility was not required to notify the POA that the 4th blood sugar check was dropped. HSD stated that she explained to the resident, before reaching out to resident's physician, that the 4th blood sugar check may be discontinued and the resident was in agreement. Based on information obtained, the facility was correctly following physician's orders for monitoring resident's blood sugar.

Based on information obtained, LPA finds the above (2) allegations 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.

As a result of this investigation, no deficiencies were cited, per Title 22 Regulations, Division 6, Chapter 8.

Exit interview conducted. Copy of report sent to Administrator for signature. Copy with signature to be returned to CCLD by end of day, 9/23/20.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2020

LIC9099 (FAS) - (06/04)

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