The Covington.

The physician's report also indicated R1 could communicate their needs. R1 had a diagnosis of cardiovascular disease, hypertension, and transient ischemic attack. R1's most recent physician's order dated April 21, 2022 included blood thinning medication for R1's conditions. LPA was unable to review home health records as they were not available. LPA interviews with three out of four staff stated they were familiar with R1. Three out of three staff stated R1 was using topical steroid cream on a daily basis for itch relief and could cause thinning of the skin when used often. Two out of three staff added in-service training was provided to care giver staff regarding the repositioning and transfers of R1 to minimize bruising and skin tears. One out of three staff added R1 was on blood thinners and that would have contributed to R1's bruising and instructed R1 to call for help when ambulating. On August 10, 2021, R1 had a fall with skin tears. Tears were treated. Home Health was requested and approved by physician. On January 4, 2022, R1 had a fall with skin tears. Tears were treated. Physician was notified and provided treatment plan. On March 5, 2022, R1 had a skin tear that was treated. Physician was notified and provided treatment plan. On March 10, 2022, R1 had a fall with skin tears. Tears were treated and physician and daughter were notified. On April 13, 2022, R1 had a fall with skin tears. Tears were treated. R1 was sent to the hospital for further evaluation due to hallucinations. R1 was discharged from the hospital and returned to the facility on April 18, 2022. R1 was placed into hospice on April 18, 2022 due to diagnosis of cerebral atherosclerosis. R1 passed on April 25, 2022. Therefore based on staff interview and records observed, the allegation of r esident sustained multiple wounds while in care is therefore deemed unsubstantiated meaning 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. An exit interview was conducted and a copy of the report was left with the facility representative.

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit to The Covington. The purpose of today’s visit was to conduct the Annual Required inspection. LPAs were allowed entry into the facility and explained the reason for the visit. Facility is licensed for 343 of which 160 may be non-ambulatory and 6 bedridden. There are a combined total of 217 residents today including independent living, assisted living and memory care. Facility has an approved hospice waiver for 15 residents and the facility currently has 13 residents on hospice care. Cash Benton has an administrator certificate expiring on 11/28/2026. LPAs Lyman and Mendivil along with Assistant Living Director Irene Falcon toured the facility at 8:51 AM. Administrator Cash Benton joined the tour in progress. LPAs toured the physical plant, checked food service, facility records and the first aid kit. Facility appears to be clean, safe, and sanitary. Facility consists of a four story independent living building, twenty two independent living cottages and a two story assisted living/ memory care building. Throughout the different buildings, LPAs observed multiple outside areas, two dining rooms, beauty salon, fitness area, theater, activity areas and a secured swimming pool. Resident apartments had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 106 and 110 degrees F in facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Staff responded within 5 minutes for emergency pull. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had required elements including thermometer and scissors. LPAs observed cleaning supplies are secured. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Facility is keeping a log of freezer/ refrigerator temperatures and were within range. CONTINUED ON LIC 809C DATED 06/05/2025 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Smoke detectors and fire inspections are conducted annually by an outside company, Cosco with the last inspection date in September 2024. Facility has carbon monoxide detectors in resident rooms and are tested by Cosco as well. Fire extinguishers are fully charged. LPAs observed evacuation chairs at stairwells. LPAs toured the outside grounds and there is ample shaded seating for residents. LPAs observed ample emergency food and water. LPAs reviewed the emergency disaster plan and infection control plan during the visit. Plans are thorough and complete. Facility conducts quarterly emergency drills with the last drill conducted on 02/19/2025. Facility provides activities in the form of games, exercise, and outings in the community. LPAs observed residents participating in activities during the visit. LPAs spoke with residents during the visit who stated satisfaction with facility services. LPAs observed no health or safety concerns during the visit. LPAs reviewed select resident and staff files. Resident files contained required documents including admission agreements, current physician reports and resident appraisals. Staff files reviewed contained required documentation such as health screen/TB, training and criminal record clearance. LPAs reviewed medication administration and storage. Medications are stored in a locked medication cart. Medications are being administered per physician order. Based on the observations made during today's visit, no deficiencies are being cited. Exit interview conducted and a copy of this report was given at time of visit.

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on fire evacuees relocated to the facility. LPA was greeted and granted entry into the facility and explained the reason for the visit. On 01/08/2025, facility accepted 23 evacuees from their sister facility MonteCedro in Altadena. Select staff from MonteCedro are working at the facility as well. At 1:00 PM, LPA toured the facility and observed the following: Facility appears clean and sanitary. LPA observed ample emergency food and water as well as the emergency disaster plan. LPA spoke with evacuees who verbalized satisfaction with facility services as well as feeling safe and taken care of. Facility has provided clothing and incidentals to the evacuees. Facility estimates a stay time of approximately three weeks. No health and safety concerns noted. Exit interview conducted and a copy of this report was left at the facility.

Licensing Program Analysts (LPA) Amy Rodgers conducted an unannounced Required One Year visit to ensure substantial compliance with Title 22 regulations. This facility is co-licensed as a Continuing Care Retirement Community (CCRC) for up to 343 resident capacity, of which is 160 is non-ambulatory on the 1st and 2nd floors only and 6 bedridden on the first floor only. Hospice waiver for six (6). LPA was granted entry into the facility and was met by Executive Director (ED) Cash Benton with whom LPA discussed the purpose of the visit. LPA was accompanied by Executive Director Benton, during a tour of the facility, which was conducted inside and out including a sample of resident units, the dining area, recreation rooms, outside grounds, and food storage areas. Exterior and interior passageways were free from obstructions. Pathways were free of obstruction and slip hazards. There is an indoor pool securely locked and accessible by key card to residences. There are waters features throughout the facility that are only accessible to independent residents. Smoke and carbon monoxide alerts are hard wired to a central location. All doors and elevators were operational. Emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Each resident had clean and sufficient bed linens. All extra linens towels, and washcloths are all accessible in rooms or in locked facility storeroom. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. [CONTINUED ON LIC 809-C] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 CONTINUED FROM 809] Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted and available through the facility communication application. Central cleaning supplies were stored in a locked closed room. Centrally stored medications were properly stored and locked in medication carts. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions. Staff records review verified that all staff records are complete and compliant. LPA conducted a thorough review of In-service training procedures. All direct care staff have current First Aid and CPR training. Resident records reviewed and confirmed compliant. Administrator’s certification is current. LPA interviewed multiple staff and clients. The interviews did not raise any significant licensing concerns. LPA reviewed the theft and loss policy and procedures. Transportation procedures are compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted, this report was discussed with Executive Director Benton. The report along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to Executive Director Benton.