347003994-2-16-2021-27-AS-MSEY-BYCUXY-20210218145907

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003994
Report Date: 02/16/2021
Date Signed: 02/16/2021 05:08:31 PM

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
07/24/2020 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200724144637

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: 65	DATE:	02/16/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Bill Phelps, Interim Executive Director/Regional General Manager		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff failed to provide adequate supervision which resulted in resident sustaining a fracture which resulted in death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility to deliver findings to a complaint investigation received on July 24, 2020. LPA met with Bill Phelps, Interim Executive Director/Regional General Manager, and explained purpose of visit. LPA was wearing an N95 mask and was cleared per department protocol per Covid-19 measures prior to arriving at the facility. LPA was also screened per Covid-19 precautionary measures upon entering the community.

During the investigation, LPA interviewed Care Director, Health and Services Director, Maintenance Director, Administrator at the time of the incident, (8) caregivers/med-tech staff, and resident’s responsible person. LPA reviewed the following documents including, but not limited to, resident’s (R1’s) physician’s reports, care plan, narrative charting notes, Unusual Incident/Injury Report (LIC624), internal investigation report, staffing schedules, pendant response log, motion sensor log for resident (R1), 911 Incident Report and supplemental Emergency Medical Technician (EMT) report, hospital medical records, and county death certificate.

The results of the investigation are as follows:

Allegation: Facility staff failed to provide adequate supervision which resulted in resident sustaining a fracture which led to resident’s death.

cont on 9099C(1)...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

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 7

Control Number 27-AS-20200724144637

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: 02/16/2021

NARRATIVE

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9099C(1)..Resident (R1) moved to community on/around January 2016. Physician’s report dated 1/15/2016 indicates that resident has Mild Cognitive Impairment and is confused and disoriented, due to “Unspecified Dementia”, but is able to follow simple instructions. Physician’s report dated 5/15/2019 notes resident has a primary diagnosis of Dementia, needs “fall supervision”, is wheelchair bound and has a slow progression of dementia. Care Plan dated 4/15/2020 documents that resident has a potential for falls, confusion and memory loss related to time and place orientation, poor safety judgment and evening confusion about where her room is. Interviews confirmed resident always lived in the same Assisted Living unit on the second floor.

Interviews indicated that resident (R1) was very independent but needed some assistance with dressing, showering, supervision with using the wheelchair to get to the restroom, and medications. Interviews revealed that resident showed some physical and mental decline in the last two years and cognitively would have been “okay in Memory Care” but was better suited for Assisted Living physically. Two staff stated that resident would have been better placed in Memory Care due to being “forgetful all of the time” and waking up at night sometimes and getting in her wheelchair. Interviews with staff further revealed that resident would sometimes be confused on her surroundings, especially at night, and would occasionally ask where her room was, but could follow directions and find her way back to her room. One staff stated that resident’s occasional confusion was conveyed to Care Director during daily cross over meetings over a year ago; however, Care Director stated she doesn’t recall having a discussion about moving resident to Memory Care and indicated that resident was suited for Assisted Living, stating “She was very acclimated to the area. Sometimes at night, she was very confused", but could find her way to her room.”

Additionally, interviews revealed that after the Covid-19 lock-down began and residents stayed in their rooms, resident was “forgetful all of the time” and exhibited increased confusion, particularly about resident’s surroundings, and would ask “where am I”. One staff stated that resident “did pretty well in Assisted Living until the lock-down” and lots of other residents were wandering after the lock-down, stating “a lot of the confusion is due to the lock-down”. Multiple staff stated that before the lock-down, resident would come downstairs and use the elevator with her wheelchair and also go out on the patio. Staff indicated resident would scoot around in her wheelchair down the hall, knew how to use the elevator and was familiar with the layout of the building and would always use the bathroom and had her purse with her.

Health Services Director at the time stated that resident did not do any wandering at night and she didn’t “know the rationale behind the incident in question and that perhaps the quarantining caused resident some confusion.” Administrator at the time stated that "we did not notice any decline in (R1) that she needed to move to the first floor" and this "change with (R1) was out of the blue and we had no warning".
cont on 9099C(2)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 27-AS-20200724144637

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: 02/16/2021

NARRATIVE

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9099C(2)..Caregiver staff who last worked with resident on 7/15/2020 and on 7/16/2020, stated resident was slightly more confused on these days", and resident stated “someone was changing in her room” and Med-Techs knew as well. Another caregiver commented, "It was normal for her to wander during the day but she never really wandered at night". When asked if she observed any change in resident's condition on 7/17/2020 or on days leading up to 7/17/2020, a Med-Tech stated, "She was just wandering like she always did"- She would wander down the other end of the second floor and ask where her room was. She was in her wheelchair.”

Staff (S2) who attended to resident on the “pm” shift on 7/17/2020, stated “I had a hard time with her when I changed her the last couple of weeks- she didn't want to get up from bed when she needed changing, so I had to call a Med-Tech, to help me. "She was agitated at night"- maybe due to staying in her room during Covid. Caregiver (S2) stated that resident was “very confused” on the evening of 7/17/2020, starting after dinner, around 6:00-6:30 pm and was told by a Med-Tech that resident went to a different hall, stating “That night, she went to the same room that belonged to another resident two times. I brought her back to her room and then she went downstairs, and the receptionist called me on the radio, around 7:45 pm, before she left at 8:00 pm, to say resident was wandering downstairs.” Another caregiver (S4) who also worked “pm” shift on 7/17/2020 confirmed in an interview “Yes she went to my side of the hallway by accident. I pushed her wheelchair and pointed her to her hall. I told her it's nighttime and to go to bed. She (R1) asked me where her room was.”

Staff (S2) stated that around 9:30 pm on 7/17/2020, she told another caregiver (S4) on the "pm" shift, that resident was "very confused again and is sitting in her wheelchair”. Staff (S2) commented, “At the same time, "I told her "one time she (R1) is going to fall down the stairs because she is "very confused". S2 clarified, “Generally, she knew her room, but she was "very confused on Friday, July 17”- she went to another resident’s room on the same floor. Caregiver/Med-Tech Staff (S1) who worked on the NOC shift on the night of 7/17/2020- 7/18/2020, stated “when I checked on her during my first round at 10:30 pm, she was sleeping in her bed already and wearing pajamas- the "pm" shift put her to bed”. Staff (S1) indicated that she did not receive cross-over shift notes from caregiver, Staff (S2), on 7/17/2020, prior to starting her shift at 10:24 pm, as staff (S2) ended her shift at 9:00 pm that night, explaining that “Usually the "pm" shift will tell me what happened during their shift”. Additionally, staff (S1) stated she has never seen resident wander before on her shift, and it was the first time that she (R1) wandered on the night she fell, on 7/17/2020.
cont on 9099C(3)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 27-AS-20200724144637

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: 02/16/2021

NARRATIVE

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9099C(3)...Internal investigation report indicates that resident (R1) was last checked on by staff (S1) at approximately 11:30/11:40 pm, during staff's (S1) first rounds, and resident was in her bed. Staff (S1) stated to LPA that resident was dressed in pajamas when she observed resident during her rounds. The motion sensor log on 7/17/2020 records motion in resident’s (R1) room at 10:02 pm, 10:50 pm and at 10:51 pm. The next motion recorded in R1’s room was on 7/18/2020 at 12:23 am and again at 12:31 am. The 911 incident report documents that emergency medical services were called by the facility on 7/18/2020 at 12:51 am and arrived on-site at 12:57 am.

Interview with Memory Care NOC shift caregiver staff (S3), confirmed that on 7/18/2020, at approximately 1:00 am, she was "just passing by the front desk" to go get some small trash bags she ran out of that are stored on the Assisted Living side and "heard a weird, loud noise". Staff (S3) explained that she walked up the stairs and found resident on the ground, on the flat landing area as she had fallen 4-5 steps from the second floor. Staff (S3) explained that she called staff (S1) "right away on the walkie", who was doing her rounds and told her she saw a resident on the floor but didn't know which resident she was. Staff (S3) explained that resident was found "facing down and her head was down, facing the wall" and resident’s "wheelchair was on top of her", stating "I took the wheelchair off of her as it looked very heavy on her" and commented, "it looks like she (R1) was trying to go down the stairs and the wheelchair went down with her". Staff (S3) confirmed that resident “was wearing pajamas and had her purse, a grey purse with her- it fell off of the wheelchair" and "she had no shoes on".

Staff (S1) stated she was doing rounds on 7/18/2020 at approximately 12:50 am when staff (S3) called her on the walkie radio to report finding resident face down on the stairway landing with the wheelchair on her. Staff (S1) stated she immediately came over to the stairway and called 911. Staff (S1) confirmed she carries a pager as a caregiver/Med-Tech during the NOC shift and received pendant alerts and motion sensor alerts on her pager for other residents during her shift on the night of 7/17/2020 -7/18/2020, but did not receive either alert for resident (R1) during this shift. Review of facility Assisted Living pendant log for the period 7/12/2020 through 7/25/2020 shows that no pendant alerts were received for resident. Staff interviews indicated that resident had a neck pendant and only occasionally used it, as she was “pretty independent”. Staff (S1) stated that resident never called during the NOC shift and staff (S2) stated that “At 2:30 pm, I would check all of the residents and I would never see that resident (R1) pressed her pendant”, explaining resident did wear her pendant as a necklace all of the time, but she "never really used it".
cont on 9099C(4)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 27-AS-20200724144637

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: 02/16/2021

NARRATIVE

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9099C(4)..Staff interviews confirmed that motion sensor alerts go to caregivers’ pagers to alert them that a resident is moving around in their room. Interview with Maintenance Director in October 2020 indicated that the facility had recently changed from the use of walkie radios and pagers by caregivers to a new radio with an earpiece used by all staff who carry them during their shift. Maintenance Director indicated that the old pagers used batteries that didn’t last long and that caregivers could replace the batteries when the pager indicated “low battery” from a supply kept at the front desk, stating, "Part of staff's job is to check the battery level and number of calls at the beginning of their shift- the old pagers were assigned and personal- everyone was responsible for checking their own pager.” Interview with Maintenance Director noted that he didn’t recall any faulty pagers being reported to him for 2020, and there were always new ones on hand.

Additionally, the facility computer system monitors the battery level in each motion sensor unit and when a low battery is detected, concierge staff will print out a report so the battery can be replaced. Maintenance Director confirmed that batteries were replaced in different sensor units within the last year and that the motion sensor unit will still work even with a low battery, commenting "It is very rare that the motion sensor is not working". Maintenance Director further explained that the if the motion sensor battery dies, the unit will stop working, confirming no sensor units were replaced in 2020, and only one was replaced in the prior year.

Maintenance Director stated that he was not aware of a motion sensor ever going off and not being received on a pager, asserting "That would be very unusual- that would only happen if they had a faulty pager." “The staff is supposed to report immediately to the care supervisor. A faulty pager would be the only reason if a call was not picked up.” Multiple staff interviews and interview with resident’s responsible person indicated that resident would move herself in her wheelchair only using her feet only and did not use her hands to help move the wheels. Staff interviews concluded that resident was slow in maneuvering herself in the wheelchair with one staff stating she "would keep looking at each side like she was "sightseeing"- she would look at the decorations on the wall- she was "very slow". Staff interviews determined that it would have taken resident between 5 to 10 minutes or longer, up to 15 minutes, to ambulate from resident’s room, past the elevator, to the stairs where she fell.

Staff (S1) stated she was doing rounds, attending to another resident, when resident (R1) fell down the stairs. Pendant response log shows that staff (S1) responded to resident (R2) at 12:02 am, resident (R3) at 12:14 am and resident (R4) at 12:21 am. The next pendant call was not received until 3:33 am and was responded to at 3:37 am by staff (S1). Both staff (S1) and Care Director confirmed that NOC shift
cont on 9099C(5)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 27-AS-20200724144637

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: 02/16/2021

NARRATIVE

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9099C(5)...staff do not get scheduled breaks or a lunch but receive an hour of extra pay to cover breaks, and there is no additional staff available during NOC shift in Assisted Living since Memory Care staff cannot leave their areas. Care Director stated that normal staffing levels in Assisted Living are three staff on the "am" and "pm" shifts each and one staff on "NOC" shift and that staffing levels did not change during the Covid-19 pandemic. Interview with staff (S2) indicated that while she was talking via FaceTime with staff (S1), who was on her break in the Activities Room, staff (S1) heard a loud crash on the stairs; however, interview with staff (S1) indicated that she called staff (S2) after resident (R1) had fallen down the stairs to inform her of what had happened. Both staff (S1) and staff (S2) indicated that staff (S2) replied "(R1) was very confused and I knew that was going to happen one time" after hearing that resident (R1) fell down the stairs.

Hospital medical records note that resident (R1) was admitted to the emergency room at the hospital on 7/18/2020 at 1:25 am with a diagnosis of Traumatic cerebral intraparenchymal hematoma, closed fracture of right zygomatic bone, subarachnoid hemorrhage, closed left acetabular fracture and closed blow out fracture of right orbital floor. Resident was placed on hospice and was scheduled to return to the facility on 7/19/2020 but passed at the hospital later that day at 6:05 pm. The county death certificates lists the immediate cause of death as traumatic brain Injury due to a fall from steps.

Based on information obtained during the investigation, LPA finds the allegation: Facility staff failed to provide adequate supervision which resulted in resident sustaining a fracture which resulted in death 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 cited on the 9099D page.

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.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 27-AS-20200724144637

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/04/2021 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident 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. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee and Interim Administrator agree to conduct staff re-training on communication between shifts, review and reinforce cross over procedures and identifying symptoms of UTI, stressing the importance of communicating to the Executive Director or Health Services Director if staff has concerns that are not being addressed. Directors to notify staff by tomorrow of importance of effective cross over communication and training to be conducted week of 2/22/2021. Documentation of training agenda/attendees to be faxed to department by 3/4/2021.
	8 9 10 11 12 13 14	Based on interviews conducted and documentation reviewed, the Licensee did not ensure that observed changes in resident's (R1) condition, including increased wandering and confusion, on 7/15/2020, 7/16/2020 and on 7/17/2020 were documented and resident's physician and responsible person were timely notified, which posed an immediate health and safety risk to resident in 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: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

LIC9099 (FAS) - (06/04)

Page: 7 of 7