347005361-9-12-2024-27-AS-KHOS-D96J6E-20240916064614

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005361
Report Date: 09/12/2024
Date Signed: 09/12/2024 11:38:46 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
05/15/2024 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240515152430

FACILITY NAME:	SUMMERSET ASSISTED LIVING		FACILITY NUMBER:	347005361
ADMINISTRATOR:	DANIELLE BARRY		FACILITY TYPE:	740
ADDRESS:	2341 VEHICLE DR		TELEPHONE:	(916) 330-1300
CITY:	RANCHO CORDOVA	STATE: CA	ZIP CODE:	95670
CAPACITY:	135	CENSUS: 90	DATE:	09/12/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Danielle Barry		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Staff are not providing adequate supervision of resident to reduce injuries
Staff did not seek medical attention for resident in a timely manner
Staff did not address resident's skin issues in a timely matter

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA Valerio met with Administrator Danielle Barry and explained the purpose of the visit.

The investigation consisted of interviews with staff, interviews with responsible parties, observation of the facility, review of medical records, review of hospice records, review of facility documentation, and review of documentation provided by the Reporting Party (RP).

Staff are not providing adequate supervision of resident to reduce injuries / Staff did not seek medical attention for resident in a timely manner

According to the Reporting Party (RP), Resident 1 (R1) "is prone to wander, fall, and suddenly injure [themselves] should [R1] be left unsupervised or not be properly cared for." RP also stated that R1 has fallen and injured R1's face on three separate occasions and Summerset has not done enough to ensure R1 is safe.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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-20240515152430

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SUMMERSET ASSISTED LIVING	FACILITY NUMBER: 347005361
	VISIT DATE: 09/12/2024

NARRATIVE

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According to R1's LIC 602 Physician's Report dated 04/04/2023, R1 is diagnosed with dementia, max supervision is needed, and it is noted to have wandering behavior in bedroom only. R1 is ambulatory. According to a Resident In-House Assessment dated 02/26/2024, R1 is on status checks 4 times per shift and ambulates independently with or without device, needs assistance with ADLs, and is not on a special care plan. The Resident In-House Assessment was updated on 05/21/2024 with minor changes. Status checks remained at 4 times per shift and ambulation requires 1 person total assist or wheelchair escort.

Facility documentation and documentation provided by the RP show that R1 sustained falls on March 11th, March 24th, and April 9th. During those days, the staff scheduled showed a total of four (4) staff members on AM and PM shift to work in the memory care living area.

According to facility documentation, an incident report dated 03/08/2024 showed that staff was on the way to an elevator when staff heard a thud. Staff turned their head and saw R1 on the floor. Staff responded and the medication technician was notified. Hospice and R1's conservator was notified of the incident. First aid was administered and it was noted that the resident did not go to the hospital. Hospice records show that a nurse conducted a follow up visit on 03/11/2024 to care for the injuries for the fall. R1 had cuts on face, Band-Aids were replaced, and R1 appeared at baseline. Another hospice entry was documented for a routine visit on 03/11/2024. The nurse wrote, "Pt fell on Friday, injuries to leg, bandage take off. No bleeding notes. No signed of infection. Checked for cut to face from fall, they are superficial cuts from the fall. Left it open to air."

On 03/24/2024, the hospice nurse was notified of a fall. The nurse documented the following: "Assess skin tears - wound to right side of face after fall this AM. Will send nurse tomorrow to cleanse and dress laceration." On 03/25/2024, the noted stated "Routine visit - checked Pt in hallways, calm/quiet, S/P fall with injuries, no signed of infection."

After 03/24/2024, LPA did not observe any additional notes from Bristol Hospice. According to an interview with the administrator, the hospice agency was not always consistent with notes and R1 was in process of changing hospice companies.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 27-AS-20240515152430

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SUMMERSET ASSISTED LIVING	FACILITY NUMBER: 347005361
	VISIT DATE: 09/12/2024

NARRATIVE

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According to a Kaiser After Visit Summary dated 04/09/2024, resident was seen for preventing falls, cellulitis, and scabies. On 04/23/2024, resident was seen at Kaiser Hospital for fall and rash.

According to an interview with R1's conservator (R1-C), R1-C stated the facility contacted R1-C each time R1 had fell at the facility. "They were pretty good about that." In regards to R1's rash, R1-C stated there was a delay because R1's medical power of attorney (R1-POA) was the initial person to converse with care staff due to the hospice company not recognizing the conservator. R1-POA told staff the rash was a food allergy. Staff were going by what the POA was saying and not a medical professional. However, according to R1-C, after emails were sent to confirm the conservatorship, R1 was able to get medical attention for the rash.

Staff did not address resident's skin issues in a timely matter

According to the Reporting Party (RP), the RP stated Resident 1 (R1) started to display signs of a skin rash in February of 2024. On April 9th, 2024, R1 was sent to the hospital for a fall and was diagnosed with Scabies. According to the RP, the facility did not address R1's skin issues in a timely manner. LPA Valerio contacted the RP on 05/21/2024 and 08/06/2024 to obtain additional information. LPA Valerio has yet to receive a response.

According to facility Medication Records, the facility administered Hydrocortisone on the following dates for the reason of rash/itching: 02/27/2024, 03/04/2024, 03/05/2024, 04/04/2024, and 04/04/2024.

According to facility Medication Records, the facility administered Benadryl Allergy 25mg tabs PO on the following dates for the reason of Rash/Itching: 02/27/2024, 02/28/2024, 03/05/2024, 03/21/2024, 03/25/2024, 04/04/2024, 04/07/2024. According to the MAR, comments shown that the medication "helps".

According to facility records, R1 had multiple visits from a Bristol Hospice nurse. During those visits, the nurse who cared for R1 wrote notes to communicate services provided. LPA Valerio observed that Bristol Hospice did not document skin care treatment until 03/11/2024.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 27-AS-20240515152430

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SUMMERSET ASSISTED LIVING	FACILITY NUMBER: 347005361
	VISIT DATE: 09/12/2024

NARRATIVE

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Per Bristol Hospice Note dated 03/11/2024, nurse wrote, "Pt was calm, cooperative, good,… still rash continue, Benadryl and hydrocortisone helps."

Per Facility Medication Room Records, a Medication Technician wrote a note on 04/09/2024 stating, "Patient has returned back to facility. New meds CATB, Acetaminophen 500mg, and body cream. Acetaminophen 500 mg did not come with other two items. CSM meds and put into QMAR. D/C paperwork to hospice. "

Per Bristol Hospice Medication Orders dated 04/17/2024, the Medication order for Bactrim and Hydrocortisone order on 04/10/2024 had been discontinued. A new order for Bactrim DS-800mg-160mg tablet 1 tablet orally 2 times a day x 7 days a week for possible infection to elbow and an order for Triamcinolone Acetonide Topical Cream 0.1% Cream application applied topically 2 times a day x 14 day for rash was ordered.

Per Bristol Hospice dated 04/11/2024, the nurse wrote, "Taking antibiotics injection on elbow. Right elbow healing. Scab notes. Pt. received meds. Scabies had shower. Spouse present."

Per Bristol Hospice note dated 04/11/2024 PM, the nurse wrote, "Routine Nurse Visit - Right elbow healing scar noted. Pt received meds for scabies. Had shower. Spouse present."

LPA Valerio interviewed 4 staff members. S1 stated that when a staff member observes a resident with a rash, the protocols were for the observing staff to notify the med tech, then the med tech will notify hospice or home health or responsible party, and then the med tech would notify memory care director. S1 admitted the previous Memory Care Director did not relay information to the Administrator timely. S2 remembers treating R1 with a topical cream for R1's rash. S2 stated the facility would communicate with R1's hospice team and R1's conservator about the rash. S3 stated if a caregiver staff sees a rash, they would take pictures and contact the doctor. If the facility has orders for medication cream, they will use it right away. S3 remember applying topical cream to R1 from the day S3 started work up until R1 left the facility. S4 could not recall treating resident for a rash.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20240515152430

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SUMMERSET ASSISTED LIVING	FACILITY NUMBER: 347005361
	VISIT DATE: 09/12/2024

NARRATIVE

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According to an interview with R1's conservator (R1-C), the facility was unaware of R1's conservatorship and was communication with R1's Power of Attorney (POA) when the initial rash was observed by staff. R1-C also stated that Bristol Hospice would not communicate with R1-C. Bristol Hospice was with R1 all the time. Per R1-C, the facility was only listening to the POA initially. The POA stated the rash was from a food allergy, so Hospice and the facility went with that and did not look into other options. Per R1-C, there was some confusion whether it was an issue for scabies or a rash from food allergy. . R1-C stated R1 was able to get care for R1's rash after R1-C sent a few emails and after R1 fell.

Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC9099 (FAS) - (06/04)

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