Wellquest of Elk Grove.

LPA Moleski interviewed Cuevas, nine staff members of this facility, and three non-staff witnesses, comprised of one resident’s family member, another resident’s friend, and an ombudsperson. In interviews, multiple staff members said that the blue-and-black chairs were lightweight, flimsy, and posed a hazard to residents in care. In an interview, Cuevas described the chairs as “lightweight,” and said that some residents were pushing the chairs back when they stood up. S1 said the chairs were replaced due to falls and due to questions of sturdiness. S1 said the chairs had a tendency to “go back,” and residents needed something sturdy. S1 said that R1 plops down heavily when they sit, and they also rock when standing up. S1 said they had observed the chairs moving around when residents rocked in them. S1 said they had concerns about the safety of the chairs. S2 said the chairs had a tendency to rock, and described them as “a bit shaky” and not “that sturdy.” S3 said the chairs were wobbly. “Anything that’s wobbly is going to be unsafe for a senior,” S3 said. S5 said that the chairs might have been unsafe. S5 said the chairs were thin, and residents tend to slam down when they sit. S5 said they had observed the chairs tipping back when residents sat down. S7 said there may have been a fall risk posed by the chairs. S7 said the chairs were very light and thin, which meant residents sitting down heavily might tip their chairs back. S7 said that R2 did have a habit of sitting down hard. S3, S4, S5, and S7 said they responded to R1’s fall as described above. S3, S4, S5 said R1 was either trying to stand up from a chair or sit down into one, although they did not witness the fall. S7 said that when they responded, they observed R1 lying back up against a window pane. S7 said it appeared that R1 had fallen backward out of the chair. S2 said they responded to R2’s fall as described above. S2 said that, upon arrival, they observed R2 on the floor propping themselves up. S2 said it appeared that R2’s chair had tipped backward. In interviews, multiple staff members were aware that loose screws had been falling out of the chairs (S1, S2, S3, S4). According to S1, screws started coming out of the chairs about a month after the chairs were first put out. In a previous interview, S1 told LPA Moleski the chairs were put out around the middle of May. In a previous interview, S1 told LPA Arielle Pascua that screws were coming out of the chairs daily. S1 told LPA Moleski that maintenance staff were re-tightening the screws. [continued on 9099-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 S2 said that any chairs that were losing screws were removed when they were noticed. S4 said that maintenance staff were reinforcing the chairs with loose screws. In interviews, visitors of this facility voiced concerns over the patio chairs. A resident’s family member said they had observed wobbly chairs and chairs with missing screws, which they removed from the area. A different resident’s friend had observed screws coming loose from chairs, which maintenance staff screwed back into the chairs. On one occasion, chairs with loose screws were removed from the area when brought to the attention of staff, according to the resident's friend. The resident’s friend had also observed the chairs wobbling and/or tipping when residents sat down heavily into them. Based on the above, facility staff were aware of issues with the blue-and-black model of chair which were used in the memory care patio area between approximately mid-May and late August 2025. These issues included a tendency for the chairs to tip and/or wobble when residents sat down into them and a tendency for the chairs to lose screws. Although some staff reported that chairs with loose screws were reinforced by maintenance or removed from the patio area, at least two visitors independently discovered screws coming loose from chairs. Despite these known issues, the blue-and-black chairs remained available to residents for more than three months. The department has determined the following as it relates to the allegation that unsafe furniture was present in the memory care patio area: Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Section 87303(a). An exit interview was held with Cuevas. Appeal rights and a copy of this report were left with Cuevas.

A review of the medication administration record for this period reflects the missed medication for 02/04/2025 due to missing medication. Based on the information gathered, the facility staff did not ensure that the resident was administered their medication(s) as prescribed. As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. An Exit Interview was conducted and a copy of this report was provided to the facility. 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 An interview with 5 residents were conducted. 5 out 5 residents state that they do not have any issues when pressing their call bells for assistance. A review of the facility call button log shows an average response time of 9-11 minutes between the months of January-Febuary 2025. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted and a copy of this report were provided to the facility at the end of this visit.

Review of R2’s admission agreement stipulates that three nutritionally balanced meals are to be made available to residents as part of their monthly fee. The agreement includes language that specifies the provision of meals and snacks, as well as the accommodation of special diets if prescribed. The agreement does not clarify whether R2 is under the Independent Living or Assisted Living rate, but it does provide that residents in the Independent Living program are entitled to two meals per day, with a third available for an additional fee. However, review of R2’s ledger revealed that R2 was paying rent for Assisted Living and not Independent Living. Further record review confirms that R2 was living in the assisted living building of the facility. Review of the email correspondence between R2’s responsible party (RP) and facility staff (S1) revealed that on 3/25/2021, RP questioned the charge for an additional meal on 3/11/2021. S1 stated that the charge was for the third meal as part of the Independent Living Program. RP clarified that R2 was in the Assisted Living Program due to an assistance with two activities of daily living (ADL). S1 then stated that R2 was being charged under the Independent Living rate which includes two meals per day and charges for the third meal. Interview with current administrator, Elena Cuevas, revealed that R2 was paying the Independent Living rate when they lived at this facility. It was also noted during the visit on 1/7/2025 that the facility’s admission agreement was updated and there were some changes, especially the verbiage under the meal section which states: " Residents paying the Independent Living rate have access to three (3) nutritionally balanced meals daily as well. Two meals are included with the core service fee and the third is available for an additional fee." This statement was added to the new admission agreement. Additional changes include Under Living Accommodations, the section Electronic Surveillance was added. It was not in the original admission agreement that was initially approved. According to California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87555 under General Food Service Requirement, (b) The following food service requirements shall apply: (1) Where all food is provided by the facility arrangements shall be made so that each resident has available at least three meals per day. This regulation contradicts the facility’s practice of charging for a third meal for resident living under Assisted Living (RCFE), where meals should be included in their basic services. Therefore, the preponderance of evidence has been met and the allegation that staff are not providing basic food services for resident is SUBSTANTIATED. {2 of 4} 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 Allegation: Facility is overcharging resident. An allegation that facility is overcharging Resident R2 for food services, specifically regarding charges for additional meals beyond the core service fee. The investigation into the allegation was based on a review of R2’s invoice, ledger, admission agreement, relevant regulations, and facility staff interviews. Review of invoice records revealed that R2 was a resident at the Assisted Living building of the facility. A review of R2’s invoice reveals that on 3/11/2021 , R2 was charged an additional $12 for a meal. Similarly, on 4/1/2021 , R2 was charged $72 for six additional meals at a rate of $12 each. R2’s ledger, covering the period from February 2021 to March 2023 , shows consistent monthly charges of $3,200 for rent and $280 for care services, which are associated with Assisted Living. Email correspondence between the Responsible Party (RP) and S1 , a facility representative, further clarifies the overcharging issue. On 3/25/2021 , RP questioned the invoice for an additional $12 meal on 3/11/2021 , arguing that R2 was entitled to three meals a day as per the contract. S1 initially explained that the charge was for the third meal, referencing the Independent Living rate, which includes only two meals, with a third meal available for an extra charge. However, RP responded that R2 was enrolled in the Assisted Living program, which should have included three meals per day. On 4/1/2021 , S1 confirmed that R2’s base rent was charged at the Independent Living rate. Furthermore, in an interview with the facility administrator , it was revealed that some residents in the Assisted Living section are being charged under the Independent Living rate, meaning they only receive two meals per day, unless they opt to pay for a third meal. The admission agreement signed by R2 outlines the provision of three nutritionally balanced meals daily as part of the core service fee for Assisted Living residents, with additional meals available for a fee under the Independent Living rate. However, the agreement does not clearly specify whether R2 is classified under the Independent Living or Assisted Living rate. Despite this, the California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87464(f)(3) , mandates that facilities provide a minimum of three meals per day. Therefore, this allegation is SUBSTANTIATED. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. {3 of 4} 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 California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Exit interview was conducted. Administrator refused to sign this report due to not agreeing with the findings. Per administrator, the same complaint was unsubstantiated on 8/25/2022. Per Administrator, they will be appealing this citation. A copy of this report and appeal rights were provided. {4 of 4}

The administrator stated that R1 was checked every two hours but walked outside to the courtyard around 1:30 PM on 10/2/2024. Morning caregiver S1 checked on R1 twice, providing water, but did not complete a shift crossover with the afternoon staff due to a meeting. R1 was last seen conscious but was found unconscious by afternoon caregiver S3, who attempted to cool R1 down before calling 911. 2 of 3 staff interviews revealed concerns of staffing shortages. S1 later expressed regret, acknowledging the incident could have been prevented with better judgment and that they felt the facility was short staffed. S4 also mentioned that they felt the facility is short staffed and there have been past complaints by families regarding the facility being short staffed and not having staff available which negatively impacted the level of care residents received. According to S4, they noticed R1 outside but did not notify staff or complete a shift crossover due to the meeting. After the meeting, S4 found R1 unconscious and helped with cooling measures. S4 also felt that the facility was extremely short on staff that negatively impacted care. According to interview, S3 was assigned to R1 in the afternoon, found R1 unconscious and moved R1 to the shade. S3 felt unfairly blamed for the incident due to communication failures and under staffing. S3 also noted that front desk person could have seen R1 on the video surveillance. S3 added that other staff had seen R1 outside earlier that day but took no action to ensure R1 was safe. Interviews revealed that facility management conducted their internal investigation and has determined to terminate S3 for the incident. Administrator stated that R1’s was not purposely neglected and that the incident was a result of a huge oversight from care staff. Administrator also stated that facility has added intervention techniques to avoid future incidents from occurring. Review of the video surveillance footage obtained from the facility cameras dated 10/2/2024 showed R1 was sitting in a patio chair in the courtyard at approximately 1:26 PM, with their body exposed to sunlight. At 1:38 PM, staff member (S1) briefly interacted with R1 for 20 seconds. Another staff member (S2) passed by R1 at 1:46 PM but did not stop. At 1:53 PM, S1 gave R1 a cup of water and stayed with R1 for about 10 seconds. At 1:59 PM, R1 was still exposed to full sunlight. Over the next hour, several residents walked past R1, and at 2:57 PM, R1 slumped over completely and was no longer visible in the chair. Afternoon staff member (S3) checked on R1 at 3:20 PM, and with assistance from another staff member (S4) and other staff, they brought R1 inside at 3:25 PM. Emergency Medical Services (EMS) arrived at 3:31 PM, and by 3:44 PM, they departed with R1 for medical care. {2 of 3} 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 Review of R1’s medical record obtained from the hospital on 10/29/2024 showed that on 10/2/2024, R1 arrived at the hospital with a core temperature of 105.3 degrees Fahrenheit with a chief complaint of altered consciousness. It was also noted that R1 had 23% to 25 % of first and second degree burns on the right forearm, foot, face, and abdomen. R1 was also diagnosed with heat stroke. On 10/3/2024, R1 had a seizure and was noted to remained comatose off sedation. It was also noted that R1’s burns began to blister. On 10/4/2024, R1 experienced fourth seizure and remained comatose. On 10/5/2024, R1 remained comatose and on comfort care. R1 later passed away on 10/62024. Review of R1’s death report confirmed heat stroke as one of the causes of R1’s death. It was also noted that R1’s injuries occurred due to direct sunlight and elevated environmental temperature exposure. Additionally, it was also confirmed from AccuWeahter.com that, on 10/2/2024, the outdoor temperature in Elk Grove, CA was approximately 102 degrees Fahrenheit. The lack of care and supervision resulted in R1’s prolonged exposure to extreme heat, causing severe injuries and subsequent death. Factors contributing to R1’s incident include procedural failures, such as the lack of a shift crossover and delayed resident checks. The preponderance of evidence standards has been met; therefore, the allegation is SUBSTANTIATED. The following deficiencies are being cited from the California Health and Safety Code (HSC) 1569.312(e). Failure to correct the deficiencies may also result in civil penalties. At the time of the complaint visit, an immediate civil penalty of $500 was issued, and AD was informed that an additional civil penalty was pending review and may be assessed according to Health and Safety Code § 1569.49(e). Once a civil penalty has been determined, the Department will return at a future date to assess civil penalty. Exit interview was conducted with AD and details of the deficiencies and plan of corrections were discussed. Per discussion with AD, they implemented plans to ensure residents’ overall health, safety, and well-being are properly monitored following the incident. A copy of this report and appeal rights were provided during this visit. {3 of 3}

On 12/3/24, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to this facility to conduct a case management visit regarding an incident occurred on 11/22/24 that the facility self-reported. LPA met with the Administrator, Elena Cuevas (AD), and explained the purpose of the visit. On 11/22/2024, an incident occurred at the facility where all Memory Care (MC) residents did not receive their scheduled morning medications due to staffing issues. The absence of a qualified medication technician (med tech) to cover the morning shift in the MC section led to this oversight. The med tech scheduled for the morning shift called out sick, and despite efforts, no other qualified staff member was available to cover the shift. Although an additional med tech was contacted to report to duty later that day, they were unable to arrive until 11:00 AM, leaving a significant gap in medication administration. A med tech in the Assisted Living (AL) section was already occupied assisting AL residents with their own medications, and it was determined that they could not assist in the MC section due to the high demand of residents needing their medication in AL. The facility’s Administrator (AD) and Residential Care Coordinator, who were not trained in medication administration, were unable to step in and help. As a result, no medication was administered to the MC residents in the morning as scheduled. In compliance with safety protocols, the AD and Health and Wellness Director (HW) promptly notified all affected residents' responsible parties, hospices, and physicians of the incident. Per AD, residents' physicians instructed the staff to just monitor the residents and not give the morning medications. They closely monitored the affected residents for a 48-hour period for any potential adverse reactions, but fortunately, no negative effects were observed. Following the incident, the facility took immediate action to prevent a recurrence. AD and HW conducted an in-service training session for the med techs, focusing on proper medication management, communication, and responsibilities, as well as dementia care. {1 of 2} 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 Additionally, the AD noted that the current Healthcare Director (HD) had been on leave and was unavailable to assist during the staffing shortage. As a result, the facility hired an interim Healthcare Director, additional Residential Care Coordinator, and three new med techs to ensure adequate staffing. A plan was also implemented to increase coverage in the AL section by adding a second med tech to the morning shift, who could be deployed to MC if necessary. The AD and HW also communicated with the residents and their families through a town hall meeting, where they discussed the facility’s corrective action plan. This plan included hiring an interim Resident Care Coordinator to serve as the Memory Care Director until further notice and appointing another Residential Care Coordinator to oversee MC and AL staff, ensuring proper support and compliance with care plans. A review of the staff schedule confirmed that, on the day of the incident, only one med tech was scheduled from 6:00 AM to 2:30 PM, highlighting the staffing challenges that contributed to the oversight. A review of the Medication Administration Record (MAR) confirmed that morning medications were not given to MC residents on 11/22/2024. Based on information gathered, the facility did not ensure that MC residents received their prescribed morning medications which was a result of unforeseen staffing issues. However, the facility took action by reporting the incident to the Department, notifying the necessary parties, monitoring residents for adverse effects, providing additional training to staff, and implementing a comprehensive plan to address future staffing shortages. As a result of this visit, the following deficiencies were cited on 809-D, per California Code of Regulations, Title 22. An exit was conducted, and a copy of the this report and appeal rights were provided. {2 of 2}

On 9/4/24, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced for the purpose of conducting a case management incident inspection regarding incident report received dated 07/02/2024 . LPA met with Executive Director, Elena Cuevas (ED) and explained purpose of visit. The incident report detailed an occurrence in which resident R1 was mistakenly given eye drops intended for another resident. This error was made by a staff member on duty (S1), who promptly reported the incident as required. Note that the incident was reported to CCLD within the reporting requirement. Upon a review of the incident report and R1's medication records, it was verified that R1 did not have a prescription for the eye drops that were mistakenly administered on June 26, 2024. During the visit, staff member (S2) provided additional details, explaining that following the incident, R1’s hospice provider was promptly notified. A skilled nurse from the hospice subsequently assessed R1’s condition. According to S2, the hospice provider did not issue further instructions but continued to monitor R1 to ensure their well-being after the error. S2 also clarified that the eye drops administered were antibiotics that had been discontinued prior to today's visit. A comprehensive review of R1’s care notes corroborated that there were no adverse reactions or negative effects from the administration of the eye drops. Furthermore, an interview with the Executive Director (ED) and a review of the incident report revealed that S1, who was responsible for the medication error, was removed from medication duties after the incident. S1 also underwent additional training to prevent future occurrences of such errors. Per California Code of Regulations, Title 22, deficiency is being cited during today's case management inspection. Note that failure to correct the citation can result in civil penalties. An exit interview was conducted with Elena and a copy of this report and appeal rights were provided to the facility.

On 9/4/24, at 10:20am, Licensing Program Analyst (LPA) Arvin Villanueva, arrived to this facility unannounced to conduct their required annual inspectiont. LPA met with Elena Cuevas, current Executive Director (ED), and explained the purpose of the visit. The facility currently has an approval to retain/accept 25 hospice residents and fire cleared to retain/accept 20 bedridden residents in the first floor. LPA and ED inspected the physical plan of the facility to ensure compliance of Title 22 regulation. Facility is a 3-story building consisting of Memory Care (MC), located in the 1st floor, and Assisted Living (AL) in the 1st, 2nd and 3rd floor. LPA observed all floors of the facility, the activity room, dining room, cinema room, elevator, and random resident apartments/units. Facility has a 170-resident capacity for both assisted living and memory care residents. Facility also has Independent Living area (IL). Facility has a pool area and was observed to be fenced, locked and inaccessible to some residents. Per interview with ED, some residents are provided supervision when they use the pool. LPA observed a shaded area in the yard with tables and chairs. Additionally the outdoor area for activities is secure for dementia residents. Outdoor passageways, walkways, driveways, and steps are free from obstructions and hazards. LPA observed medication rooms in the AL and MC side and medications were observed to be properly stored, locked and inaccessible to residents in care. The resident apartments/units are spacious enough to accommodate the residents' furnishings. 3 of 3 resident apartments/units were observed to be clean, sanitary and free of obstruction. Bathrooms were observed to be clean, maintained and in good repair. Memory care has delayed egress doors. Kitchen and dining area were observed to be clean and sanitary. During this visit, kitchen staff were observed to be preparing lunch. Sharps, cleaning supplies and toxins were observed to be locked and inaccessible to residents. Kitchen refrigerators and freezers were observed to be cleaned and in good repair and were maintained at regulatory temperatures. Hot water temperature in 1 randomly selected bathroom (in a resident apartment/units) were measured at between 115 degrees F. Room temperature in the hallways were observed between 70 and 75 degrees F. One elevator was observed to be in good working condition. Facility has 4 stairwells and 2 were inspected and were observed to have evacuation chairs. Con't to LIC809-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 LPA conducted record review of 6 resident files and 6 staff files and found to be in compliance at this time. LPA also reviewed facility emergency drill and facility conducts evacuation drills at least quarterly. During this visit, LPA discovered 2 residents in care in the AL area became bedridden status and were living in units not fire cleared for bedridden residents. LPA obtained a copy of their current resident roster, staff roster, current Liability Insurance Certificate and updated LIC308. The following deficiency was observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Failure to correct the deficiency may result in additional civil penalties. An exit interview was conducted with Elena Cuevas, ED, and a copy of this report and appeal rights were provided.

On 12/21/23, at 10:15am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct a case management visit on recent incident reports regarding falls. LPA met with the current Administrator, Elena Cuevas, and the facility Regional Health and Wellness Director, Rochelle Factor, and explained the purpose of the visit. During this visit, LPA reviewed fall incident reports and resident files for Resident_1 (R1), R2, R3, R4, R5, R6, R7 and R8. Falls were reported between the dates of 9/29/23 and 11/24/23. LPA also interviewed Elena Cuevas and Rochelle Factor. Of the 8 resident falls reviewed, 7 were unwitnessed falls. All reporting requirements for incident reports received were met per regulations. Based on interviews, it was determined that the facility has now implemented a fall prevention protocol which include frequent checks on residents in care, especially those on fall risks. Per interview, residents who had falls are put on high alert and encourage residents to enroll the EmpowerMe Wellness program which include physical therapy, occupational therapy and speech therapy. Additionally, residents who are fall risk will have their medications evaluated by their primary care physician to determine if any of their current medications can contribute to falls. Additionally, residents carry a fall pendant. Administrator and Health and Wellness Director is planning to conduct in-service training next week to address falls and incident reporting. A discovery during a resident file review that a death report was submitted to the Department on 11/13/23. However, review of the death report indicates that the date of death of the resident was on 10/30/23. Per interview confirms the date on the death report and the reporting date are accurate. Per California Code of Regulations, Title 22, deficiencies were observed or cited during today's case management inspection. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. An exit interview was conducted with Elena Cuevas and a copy of this report and appeal rights were provided.

Continues from LIC 9099 Based on review of the facility records obtained by LPA on 09/01/2023, there was an order dated and signed on 05/09/2022 by a physician for the following: Neutrogena Invisible daily lotion - apply as directed on tube to the face, ears, neck as needed - SPF 60+, Neutrogena ultra sheer SPY 70 - apply as directed on bottle as needed to the arm and legs. According to Medication Administrator Records (MAR) for May of 2022, LPA observed sunscreen being provided on 05/16/22, 05/18/22, 05/23/22, 05/24/22, 05/25/22, 05/30/22, and 05/31/222. The dates that it was provided was provided by the same staff member each time. LPA observed a trend where primarily the same staff member was the individual to assist with the PRN. During October 2022, November 2022, December 2022, January 2023, February 2023, March 2023, the PRN for specific cream was not provided for R1. On 04/04/23, R1's treating physician wrote a letter and provided orders to update the sunscreen from a PRN to a daily prescribed cream. According to MAR records for April 2023, the PRN orders did not change. MAR records reviewed for May 2023 show that the facility started an order effective 04/04/2023 for "Sunscreen lotion and spray and hat - not given by facility". There were no signatures noted for this order; however, there are signatures for the previous PRN orders. On 05/09/23, another physician submitted an signed order to the facility. "Dear Care Team: Please apply the below sunblock lotion... before spending time outside. Banana Board Kids Sport 50 Powerstay Technology Tear and Sting Free. Based on review of the MAR for May 2023, the facility inputted it as a PRN. This was discontinued in October of 2023. Facility Records and Medical Records show that Topical creams Calcipotriene and Flurorouracil was ordered to start on 09/22/22, however, cream was not applied until 09/26/22 during PM shift due to not receiving the creams and "daughter requesting the start of cream on 09/27/22 due to doctor wanting the family member to teach medication technicians on how to apply the cream." According to a staff interview, the facility does not create the MARs. The MARs are created by Yorba Linda Pharmacy, an outside agency. Based on medical record review, interview, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was provided. 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 Continues from LIC 9099 - A The pictures show that R1's face is red on the sides of R1's temples down to R1's entire cheek and across R1's nose. According to Medical Records, R1 was seen by a Physician on 05/09/2022 at due to excess exposure to the sun and left with an order for the "nursing home to apply sunscreen." According to Medical Records, R1 was seen by a Physician for a skin check. Records indicate that R1 was diagnosed with Actinic Keratosis. LPA searched Actinic Keratosis on google. According to Mayo Clinic Web Search, Actinic Keratosis is a rough, scaly patch on skin, hard, wartlike surface, with a skin appearance of color variation, including pink, red or brown caused by frequent or intense exposure to ultraviolet rays from the sun or tanning beds (Mayo Foundation for Medical Education and Research, 2023). On 09/22/22, R1 was treated for sun damaged skin. Medical Records show that the R1 was seen by the same physician in April of 2023, May of 2023, and October of 2023. LPA attempted to interview 6 staff members (S1 - S6). 1 staff member denied answering questions, 2 were unavailable, and 4 were deemed successful. S3 stated that all staff have the responsibility to check on the residents who chose to sit outside. Residents have the right to sit outside if they chose; however, staff are to assist with needs, such as offering water, redirecting to shade, or prompting. Staff stated that if a resident does not listen or oblige to prompt, staff cannot force the resident to do anything. S3 stated they always put sunscreen on R1 since last summer but could not speak to any other staff. S5 stated if there was ever a resident sitting outside for too long, S5 would make sure to take the resident out from the sun. S5 does not recall any resident's sitting outside for a long period of time. Based on file review of facility records, there is no record of R1 being observed sitting outside for an extended period of time without staff intervention. 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. An exit interview was held, and a copy of report was provided. 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 LIC 9099 - A According to S5, the facility has training but feels that the current staff need extra training on how to care for residents on the memory care side. S5 stated they are unaware if anyone at the facility has an order for sunscreen. According to Staff 7 (S7), the facility has all employees to go through an orientation checklist. Each individual will go through 9 hours of online topics, Relias General Topics, 2 days of shadow training, along with a supervised medication pass, CPR refresher, and review with working with Pharmacy, Med Room and EHR protocols. Additional training is provided by the Health and Wellness Director and the Resident Care Coordinator. LPA reviewed facility training files. LPA observed 6 staff files to have 20-40 hours of completed training prior to being left alone on the floor. Based on records review, the facility has copies of additional in-service training provided by management staff. 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. An exit interview was held, and a copy of report was provided.