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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005361
Report Date: 06/21/2024
Date Signed: 06/25/2024 04:39:22 PM

Substantiated


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
11/28/2023 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20231128084622
FACILITY NAME:SUMMERSET ASSISTED LIVINGFACILITY NUMBER:
347005361
ADMINISTRATOR:ELISA WEATHERSFACILITY TYPE:
740
ADDRESS:2341 VEHICLE DRTELEPHONE:
(916) 330-1300
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:135CENSUS: 83DATE:
06/21/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Danielle Barry TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff do not ensure resident rooms are kept clean.
Staff do not ensure that resident has a working call button.
Staff do not follow infection control practices.
Resident developed a stage 3 pressure injury while in care.
Staff retained resident with a prohibited health condition.
INVESTIGATION FINDINGS:
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On 6/21/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator (DFA). LPA met with Danielle Barry who assumed her on position on 2/16/24. At the time census was 83 with 30 residing in memory care.

LPA conducted a walkthrough of the facility. LPA observed 7 residents in the assisted living dining room having breakfast and the Resident Services Director distributing medications. In memory care, LPA observed a med tech distributing medications room-to-room. LPA also observed 7 residents finishing breakfast in the dining area and another 7 residents watching T.V. in the common area. LPA observed the DFA assisting a resident to the elevator as they were being picked up for a doctor's appointment.
There were 2 care staff in the kitchenette area cleaning up, and the Director of Maintenance was steam cleaning the floors and carpeting throughout the area. LPA also observed 1 housekeeper cleaning the bistoro area.



Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
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 8
Control Number 27-AS-20231128084622
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: 06/21/2024
NARRATIVE
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until a later time to be addressed since the care staff was needed to provide direct support and supervision to the residents.

The preponderance for the standard of evidence has been met and the department finds the allegation, "Staff do not ensure resident rooms are kept clean," to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099 D page.

Regarding the allegation: "Staff do not ensure that resident has a working call button."

Based on interviews with 3 staff members, residents in memory care do not have a working call button to alert staff that they need assistance. There were no call buttons located at their bedsides and S7 stated,
"That is probably why we had so many unwitnessed falls; they don't have a way to ask for help when they want to get out of bed."

On 6/14/24, this LPA observed the alert system set up in the bathrooms in memory care including room 225. The pull cords were wrapped around the units and therefore could not be activated. The units also had a button that could be pushed, but as there was no signage or markings on the plain gray circle, it was not obvious that it was a button or what would happen if it was pushed. LPA took photos for documentation purposes.

Based on interviews and observations the allegation, "Staff do not ensure that resident has a working call button," has been SUBSTANTIATED. The preponderance for the standard of evidence has been met and this deficiency has been cited on the LIC 9099 D page.

Regarding: "Staff do not follow infection control practices."

Based on a review of the housekeeping schedule and interviews with 3 staff members at a supervisory level, at the time of the complaint, staff were wearing necessary PPE when required due to the health status of residents in care. However, due to limited staffing, rooms were not being cleaned immediately following resident's toileting accidents and staff were not preventing residents from wandering the floor and touching surfaces that had not been disinfected. 2 of the 3 staff members interviewed stated that the restrooms in the common areas of memory care were not being disinfected between resident use.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 27-AS-20231128084622
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: 06/21/2024
NARRATIVE
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Their own infection control plan stated on page 2 section 2 that: "Blood and body fluids clean up shall be cleaned up immediately and disinfected. Gloves and proper PPE to be worn and all items put in biohazard bag (red bag)."

Based on the information above, the preponderance for the standard of evidence has been met and the allegation, "Staff do not follow infection control practices," has been SUBSTANTIATED. This deficiency is cited on the LIC 9099 D page.

Regarding the allegation: "Resident developed a stage 3 pressure injury while in care."

The department learned through a review of records, that on 11/04/23, it was noted that resident (R1), had a "black mark on R1's coccyx area. Per staff, the protocol is to contact the resident's doctor if an unusual mark is noticed on a resident's body the day the mark is noticed. On 11/07/23, it was noted that R1 had a telephone appointment with their doctor, (D1) and there were no notes indicating that the mark on R1's coccyx was discussed. D1 was not notified of the mark until 11/08/23 via fax. LPA reviewed the fax that indicated R1 had an "open sore." A response was not received from D1.

Records also indicated that on 11/13/23, 9 days after a spot was first observed, R1 was sent to Kaiser Permanente Roseville for an "open sore" and it was noted that R1 had an unstageable wound on her coccyx. On 11/15/23, R1 was discharged from Kaiser Permanente Roseville with a diagnosis of "pressure ulcer of sacrum, unspecified stage." Staff reported R1 was incontinent and bedbound after R1 went to the hospital in October 2023 for a fall. Staff reported that R1 was on a two-hour rotation.

In an interview with the Memory Care Director at the time of the incident, (S4) the department learned about the body checks conducted by the care staff. S4 stated that if a caregiver notices a rash, pressure injury, or skin tear than the caregiver will advise the med tech on shift. The med Tech will then fax the resident's doctor and determine what they need to do for care. If the med Tech does not get a response from the doctor, then the resident would be sent to the hospital if its regarding a pressure injury. S4 was asked how long a med tech should wait to hear back from the doctor. S4 stated, "about 3 days". After 3 days, if the med tech has not received a response, then the med tech should follow up with the doctor via telephone. S4 was asked what would happen if the pressure injury got worse during the 3 days. S4 stated that the resident
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 27-AS-20231128084622
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: 06/21/2024
NARRATIVE
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Regarding the allegation: "Staff do not ensure resident rooms are kept clean."

On 11/29/23, this LPA visited 3 resident rooms (R4, R5, R6) in memory care. In R4's room, LPA observed that there was visible dust on surfaces and there were scattered candies and bits of tissue on the floor. R5's room was very basic; no personal items were present. The air was stale, but not malodorous. R6's room was clean and organized. 11/29/23 was a Wednesday and one of the scheduled housekeeping days. 1 out of 3 rooms was not clean.

This LPA requested a copy of the housekeeping schedule for the month of November 2023 and was told that the schedules were handwritten and copies were not kept. LPA requested the hours-worked logged for that time period with the intent of interviewing specific housekeeping staff. The Designated Facility Administrator stated that the hours worked log would still not show which housekeepers were assigned to which area as they all rotate throughout the building. LPA was provided a schedule for March 2024 and was told it was the template that was used during the time of the complaint.

Through interviews, this LPA learned that there was a designated housekeeper assigned to memory care Sunday for 4 hours and Monday, Tuesday and Wednesday for 8 hours each day. The housekeeper assigned for Sunday was responsible for cleaning and dusting the common areas. Resident rooms were cleaned once a week. This LPA reviewed a cleaning schedule provided by the Housekeeping Department. On Mondays and Wednesdays, there were 10 resident rooms to be serviced. Tuesdays, the housekeeper was assigned 6 resident rooms, and that person was also responsible for mopping the sitting area and the kitchen in memory care. There was no housekeeping coverage in memory care Thursday, Friday, or Saturday.

Through interviews it was also learned that regular sweeps of rooms were not done and that if a resident had a toileting accident, spilled something or had vomited, it might go unnoticed for an unspecified period of time. If one of these accidents happened after housekeeping staff had gone home, it would be up to the care staff on duty to clean up. LPA learned through interviews that at the time of this complaint, there were concerns that additional care staff were needed to meet the needs of the residents in care. At that time, the PM shift consisted of 2 care staff and 1 med tech. There were 33 residents living in memory care at that time. Depending upon the needs of the residents at that time, any mess in a room, may have had to wait
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 27-AS-20231128084622
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2024
Section Cited
CCR
87303(a)
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Maintenance and Operation 87303 (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include... services and procedures for the safety and well-being of residents, employees and visitors.
The Licensee did not meet the above requirement as evidenced by:
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Administrator has already increased housekeeping hours in memory care. This POC has been cleared.
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Based on a records review, interviews, and observations, there were no housekeeping services assigned on 3.5 days out of 7. Care staff scheduled were not able to immediately clean and disinfect when accidents happened, and 1 out 3 rooms observed needed to be cleaned.
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Request Denied
Type A
06/22/2024
Section Cited
CCR
87303(i)(1)(A)
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Maintenance and Operation 87303 (i) Facilities shall have signal systems...(1) All facilities...16 or more...shall have a signal system which shall: (A) Operate from each resident's living unit.
The Licensee did not meet the above requirement as evidenced by:

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Administrator will provide LPA with a list of all Memory Care residents with call pendants/ room buttons and a roster for comparison. This information will be emailed to kimberly.viarella@dss.ca.gov by 6/22/24.
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Based on interviews and observations, none of the residents were provided call pendants and the did not have call alerts in their living spaces, only in the bathrooms. The unit in R1's bathroom was inoperable because the cord was wrapped around the unit.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 27-AS-20231128084622
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2024
Section Cited
CCR
87470(2)(A)
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Infection Ctrl Requirements: 87470(2)(A)
(2) Environmental cleaning & disinfection activities... (A) Surfaces ...shall be sani-tary ... soiled with blood or body fluids or other potentially infectious material.
The Licensee did not meet the above requirement as evidenced by:


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Administrator has already stocked disinfecting and cleaning solutins in a locked cabinet in each common area bathroom and completed a re-training on handwashing. This POC has been cleared.
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Based on interviews, 2 of 3 staff members stated the restrooms in the common areas were not being cleaned and disinfected between resident use.
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Type A
06/22/2024
Section Cited
CCR
87615(a)(1)
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Prohibited Health Cond: 87615(a)(1)
(a) Persons ... shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.
The Licensee did not meet the above requirement as evidenced by:



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R1 was a resident the care at Summerset Assisted Living diagnosed with a stage 3 pressure injury, which by regulation, is a prohibited health condition.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 27-AS-20231128084622
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2024
Section Cited
CCR
87465(a)(1)
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Incidental Medical & Dental: 87465(a)(1)
(a) A plan for incidental medical and dental care shall be developed... (1) The licensee shall arrange, or assist in arranging, for medical ...appropriate to...needs of residents.
The Licensee did not meet the requirements above as evidenced by:
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Administrator has hired a new Director of Memory Care, (start date 4/16/24). Administrator has scheduled an in-service with First Call Hospice to train on pressure wounds and injuries on 7/8/24.
This POC has been cleared.
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Based on a review of medical records, shower and communication logs, interviews and photographs, the facility did not send R1 out for medical assessment and treatment of a pressure injury in an appropriate and timely manner resulting in it becoming a stage 3 pressure injury.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 27-AS-20231128084622
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: 06/21/2024
NARRATIVE
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 would be sent to the hospital and would return to Summerset Assisted Living with Home Health services to provide wound care.

Staff were unable to provide a time frame as to when R1's pressure injury got worse. On 11/10/23, staff (S1) saw R1's pressure injury and stated that R1's pressure injury had a band aid on it and that it was an open wound. S1 believed that R1 should have been sent to the hospital on 11/10/23. However, R1 was not sent to the hospital until 11/13/23. S1 believed that R1 was neglected and that R1's pressure injury could have been prevented. Residents were interviewed and did not have any complaints about Summerset Assisted Living.

Based on the interviews conducted along with a review of shower logs, photographs of R1's wound, Medication Technicians Communication Log notes, and medical records from Kaiser Permanente, the above allegation was found to be SUBSTANTIATED. This deficiency is cited on the LIC 9099 D page. The department may assess additional civil penalties at a later date.

Regarding: Staff retained resident with a prohibited health condition

Based on the substantiated allegation above, this facility retained R1, a resident with a prohibited health condition. Per the interview with S4, if the doctor could not be reached, the resident should have been sent out to the hospital for medical assessment and treatment. Any change in condition requires an assessment and an updated care plan. The facility waited 9 days before sending R1 to the hospital. The facility did not seek a medical assessment of R1's pressure injury in a timely manner and R1 developed a stage 3 pressure injury, a prohibited condition. Based on the information above, the preponderance for the standard of evidence has been met and the allegation, "Staff retained resident with a prohibited health condition,” has been SUBSTANTIATED. This deficiency is cited on the LIC 9099 D page.

According to the California Code of Regulations and Title 22, all deficiencies were cited on the LIC 9099 D pages.  Civil penalties were also assessed today in the amount of $500.00.  Additional penalties may be assessed at a later date.  A copy of this report was provided along with Appeal Rights.

Exit interview.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8