Fountain Square of Lompoc.

At 9:00am on 11/06/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the facility annual inspection. Additionally, LPA issued final findings to the allegations to a separate complaint on a separate report. LPA met with Community Relations Director, Sarah Kau (CRD), LPA announced who he is and the reason for this visit. CRD made phone contact with Administrator Morgan Williams who was unavailable for annual inspection, who provided verbal authorization for CRD to sing for annual inspection report and compliant findings. This facility is approved for a maximum capacity of one hundred thirty (130) residents. All residents licensed and approved for non-ambulatory status, of which ten (10) may be bedridden. Facility is approved for delayed egress, with an approved hospice care waiver for twenty (20) residents. This facility has a main kitchen for all residents of the facility, and two (2) dining rooms. One (1) dining room is specifically for the Assisted Living residents of the facility, and the other dining room is for the Memory Care residents of the facility. CRD and LPA conducted physical inspection facility grounds outside, in-closed courtyards and building including resident rooms, storage, kitchen, dining rooms, medication room and offices. LPA observed at least 2 days of perishable food and at least 7 days of non-perishable food items maintained in the facility and sufficient emergency water supply located in the facility kitchen. LPA noted that resident rooms all have on suit bathroom. All resident rooms had required furniture and linins per regulations. LPA observed facility Maintenance Supervisor tested water in resident memory care bedroom that exceeded regulation standards of 120*(f), citation was issued [87303(e)(2)]. LPA observed chemicals stored in unlocked cabinet in memory care unit, citation issued [87309(a)]. LPA observed door to facility kitchen not operating properly and not closing as designed, and courtyard fountain in disrepair with loose rocks in the walkway surround fountain, citation issued [87303(a)]. No other citations or violations noted during the physical inspection of the facility. CONTINUED on LIC9099-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 observed fire extinguishers lactated throughout the facility all primed and in the green indicating working. LPA reviewed annual fire inspection dated 07/14/2025 from Securitas Fire Systems showing visual and functional test of sprinkler fire system with a grade of passing. LPA noted that there are complete first aide kits in memory care, kitchen and medication room. LPA noted that all hallways, sliding doors, doors and passageways were free and clear of debit. CRD and LPA conducted a full review of the annual care tools. LPA reviewed Emergency Disaster Plan, Infection Control Plan, Liability Insurance, and Centrally Stored Medication Records. LPA reviewed a sample of Staff and Resident files. LPA noted that there were no other violations or citations issued as a result of the document and file reviews. LPA noted no other citations or violations as a result of this annual facility inspection. Exit Interview, report read, report and appeal rights provided.

On 08/13/2025, LPA Jeffries reviewed the facility provided call button response schedule for R1’s room from 06/24/2025 through 07/17/2025 (24 days) Tilted: Resident Incident Details Report: This report shows a total of 668 Resident Incident calls from R1’s room. Of those 668 calls, 221 calls took over 10 minutes for staff to respond to clear call button (33% of calls); of those 221 calls over 10 minutes, 86 (13% of calls) of the calls took over 20 minutes for staff to respond and clear. Serious Incident Report (SIR) from facility dated 06/24/2025 shows R1 calling 911 for chest pain at 9:50pm, on 06/24/2025 the last call button for R1 was pressed at 6:58pm and shows 42 minutes and 39 seconds to clear (42:39). SIR dated 06/29/2025 shows R1 calling 911 for chest pain at 12:30pm, the last call button press for R1 prior to time on this SIR was 12:16pm with staff clearing call 30 minutes and 14 seconds (30:14) later when Emergency Medical Technicians (EMT) arrived to the facility for R1’s 911 call, R1 refused transport at that time. SIR dated 06/30/2025 shows R1 called 911 for back pain at 7:30am. R1’s last button press to this SIR was 7:09am, 24 minutes and 23 seconds later (24:23) that call button press was cleared. SIR dated 07/03/2025 shows R1 calling 911 at 8:50am, R1’s last button press to this SIR was at 7:58am, call button was cleared 39 minutes and 26 seconds (39:23) later. SIR dated 07/04/2025 at 9:00pm showed R1 called 911 due to throat closing, the last call button press in relation to this SIR was 8:49pm, log shows this call button being cleared 32 minutes and 40 seconds (32:40) later. LPA noted that 5 SIR’s for calling 911 all show call response times by facility staff exceeding 24 minutes or more. LPA noted that on 04/03/2025 the facility was cited on a complaint for required signal system [87303(i)(1)(C)]. and as the plan of correction for that citation was to have all pendants (call buttons) reprogrammed by 04/17/2025. This POC was confirmed by email on 04/17/2025 that all pendants were working. Based on 33% of the button calls for incident for R1’s room took 10 minutes or more for staff to respond and 5 documented SIRs showing call times exceeding 24 minutes, and interviews, there is enough evidence to support the allegation of ““Staff do not respond to resident call for assistance in a timely manner” and is substantiated at this time. Exit interview, report read, citation issued, report and appeal rights 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 The next time R1’s call button was pressed was 3:50pm, approximately 7 hours in between calls and approximately 6 hours after R1 called F1 to alert for incontinence. According to F1’s interview, R1 had been changed by staff on or before 10:15am on 07/11/2025. However, there was no call button to summon staff for assistance from R1’s call button after 8:56am. On 07/14/2025, LPA interviewed Direct Care Staff (S1, S2, and S3), all stated that R1 required at least 2-person assist with incontinent care and showering but only wanted assistance from direct care staff who was not on duty during the day shift and refused direct care assistance for incontinence and showering. Based on interviews of F1 stating staff had difficulty helping R1, with cleaning and changing on 07/11/2025, and no indication of call button being pressed at time alleged in complaint, staff and R1’s interviews of R1’s right to refuse, and documentation there is not enough evidence at this time to support the allegation of, “Staff do not ensure that resident's toileting needs are met”, “Staff do not ensure resident's showering needs are met.” and are unsubstantiated at this time. As to the allegation of, “Staff handled residents in a rough manner.”, it was alleged that R1’s first day at the facility, 5 direct caregivers attempted to change R1 in a rough manner. It was discovered through interviews, and documentation that on 07/14/2025 LPA conducted an interview with F1 and R1, who stated that 4 staff members were trying to move R1 in ways that worked for them and not R1, and one staff member was just watching and not helping. On 07/11/2025 In interviews with S1, S2 who were working on 06/24/2025. S1 and S2 stated that R1’s behavior in the incontinent change that day made it difficult for staff to change R1 and they were attempting to work with R1 to make it work in light of the behavior to resist the assistance of staff. S1 and S2 stated, there was only room for 4 staff to help and they do not remember the 5th staff present on 06/24/2025. On 07/14/2025, LPA reviewed staff training on all facility direct care staff members, all staff are current and up to date on annual regulated training requirements which included training on resident transfers. On 08/13/2025 LPA reviewed R1’s Resident Assessment, which indicated that R1 required a 2 person assist with transfers, bathing, toileting, and dressing. Based on interviews indicating resisting staff care and documentation of regulated staff training, there is not enough evidence at this time to support the allegation of, “Staff handled residents in a rough manner.” and is unsubstantiated at this time. CONTINUED on LIC9099-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 As to the allegation of, “Staff so not provided adequate food service.” It was alleged that staff leave food for R1 across the room, where R1 could not reach food. It was discovered through interviews that on 07/14/2024 LPA conducted interviews with R1 who stated that they do not like the food at the facility. R1 stated,” a few days ago (did not remember specific date) dinner was delivered when I was sleeping and when I woke up it was cold. R1 stated that they had to call staff (via call button) in order to reach dinner.” On 07/11/2025, LPA interviewed S1, S2, and S3, all who stated that they had never seen meals being placed out of reach of R1’s bedside. On 08/13/2025, LPA reviewed facility’s call button report for R1’s room, which shows approximately 650 calls for service answered in a period of 22 days. On 07/14/2025, LPA reviewed R1’s Physicians Report (LIC602) singed and dated on 06/24/2025, which indicated that R1 is “able to feed self”. And Facility Resident assessment dated 06/27/2025 which indicated that R1 “Requires food cut chopped, pureed, or otherwise prepared.” With no other assessments pertaining to meals. Based on documentation, interviews, and staff observations, there is not enough evidence at this time to support the allegation of, “Staff do not provide adequate food service.” and is unsubstantiated at this time. Exit interview, report read, and report provided.

The “Resident Incident Details Report” that was provided by facility, which shows 20 calls from R1’s room, dating from 04/13/2025 through 05/07/2025. 14 of 20 calls showed a response time ranging from approximately 11 minutes and 22 seconds (11:22) to 1 hour 49 minutes and 46 seconds (1:49:46) resulting in late responses average of approximately 41 minutes per late call, of the 14 late calls. And 1 minute and 35 seconds (1:35) average per the 6 acceptable call response times. At this time there is sufficient evidence to support the allegation of, “Facility did not answer residents call button in a timely manner.” and is substantiated at this time. Exit interview, report read, appeal rights and report 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 “Identified concerns and recommended actions take to resolve” entry to that form. LPA also noted that Outside Agency Service and Documentation form showed 52 prior visits without any additional concerns for R1 prior to the month of May 2025. Based on interviews, and documentation, there is not enough evidence to support the allegation of, “Facility did not ensure residents’ care needs were met.” and is unsubstantiated at this time. As to the allegation of, “Staff violated residents’ personal rights.” It was alleged that on 04/17/2025, R1 was not allowed to go to bedroom from the activity room. It was discovered through interviews and documentation that, on 06/26/2025, LPA Jeffries conducted an interview with S1, S2, and S3, all who stated that another Resident (R2) in Memory Care attempted to push R1 in their wheelchair into R1’s Room. All 3 staff stated that R1 and R2 were redirected back to the activity room for the safety of both residents. All 3 staff denied not allowing access to R1 to their room at any time other than R2 going into R1’s room for safety concerns. LPA Jeffries reviewed the staff schedule for 04/17/2025 and confirmed that S1, S2, and S3 were working in memory care on 04/17/2025. LPA Jeffries reviewed training for S1. S2, and S3 and all staff were current in the required staff training hours. R1 was no longer a resident at the facility and could not be interviewed. On 06/26/2025 LPA Jeffries attempted to interview R2, however R2 was not able to answer questions about 04/17/2025. At this time there is not enough evidence to support the allegation of, “Staff violated residents’ personal rights.” and is unsubstantiated at this time. As to the allegation of, “Facility was not maintained sanitary.” It was alleged that staff did not clean R1’s room or make R1’s bed, when wet with urine and floor had dried urine. It was discovered through interviews, documentation and observations that on 06/26/2025, LPA Jeffries conducted a physical inspection of the facility with focus on Memory Care Unit and room that R1 had resided over a month past. LPA noted that there were two housekeepers working in memory care unit and there were no overt smells and the facility and memory care appeared clean and in good repair. LPA noted that R1s former room was clean, floors were clean and discovered no issues in R1 former room. On 07/10/2025, 07/14/2025, and 07/22/2025, LPA conducted a physical walk through of the facility including memory care unit. LPA noted that the facility was clean and in good repair and noted at least two or more housekeeping staff working to clean rooms during these visits. LPA reviewed the facility schedule and noted that housekeepers were consistently scheduled during the months of April and May of 2025, additionally Care Staff was also consistently scheduled during April and May of 2025. Based on observations, and documentation there is not enough evidence to support the allegation of, “Facility was not maintained sanitary.” and is unsubstantiated at this time. Exit interview, report read, appeal rights and report provided.

At 10:45am on 07/22/2025, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to conduct a case management visit pertaining to the serious incident report (SIR) on the date of 07/11/2025, of staff bringing loaded gun into the facility. On 07/14/2025, it was reported that on 07/11/2025, Staff 1 (S1) had brought a loaded gun into the facility, in the kitchen storage area, as reported by staff. Administrator Robin Murray and Community Relations Director (S4) inspected the kitchen where they discovered a gun in a drawer. Administrator immediately called Lompoc Police De partment (LPD) who arrived and confirmed that the gun was loaded with 9 live rounds 9mm ammunition. According to LPD Police Report. S1 was taken into police custody along with all physical evidence. Administrator stated in the SIR that S1 was placed on administrative leave pending due process termination. At the time of visit Administrator stated that S1 had been terminated and presented paperwork indicating S1 had been terminated. As a result of S1 bringing a loaded gun with 9 rounds of live ammunition and leaving it in a accessible common drawer, the facility is issued a citation of 87309(a) Storage Space and Access. Exit interview, report read, citation, appeal rights and report provided.

At 9:15am on 07/10/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct a case management visit pertaining to Serious Incident Reports (SIR) from the facility, reviewed from March 2025 through June 2025. Upon arrive to the facility and entering at 9:15am there were no staff at the entrance, LPA singed in and walked into the facility. LPA walked down to the left side hallway and discovered the Med room unlocked and unattended. LPA called Administrator by phone and left a message on Administrators cell phone. LPA met with Resident Care Coordinator, Veronica Guinea (RCC), , announced who he is and the reason for the visit. LPA Jeffries took a short video of the unsecured medication room searched and found staff and asked staff to secure medication room. LPA noted that there were 5 residents in the dining room and 2 residents walking the hallway near the medication room when LPA discovered the unsecured and open medication room. LPA called Administrator on cell phone to request her presents at the facility at 9:30am. Facility will receive citation, 87465(h)(2) Incidental Medical and Dental Care, medications accessible to persons other than responsible employees. LPA Jeffries reviewed SIR's from the facility during the months of March 2025 through June 2025 and noted at least 18 SIR's with late and/or missing information as required by Community Care Licensing (CCL) Regulations 87211. LPA Jeffries noted that there were two verbal warning by LPA Jeffries to Administrator, Robin Murray about regulation reporting requirements of SIRs being submitted past the 7 days within the occurrence to report regulation requirements (87211(a)(1)), on 04/03/2025 and 04/30/2025. CONTINUED on 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 Jeffries followed up with an written warning of late SIRs in an email sent to Administrator on 06/18/2025, and followed up with an email to Administrator of copy of CCL 87211 reporting requirements sent to Administrator on 06/20/2025. In reviewing SIRs dated from March 2025 through June 2025 LPA noted that there were 105 SIRs submitted by the facility. 18 of 105 were submitted after the 7 day requirement. LPA also noted that 7 of 105 SIR's had no attending physician's name, findings, and treatment, if any; and disposition of the case when residents had returned from the Emergency Room (ER) visits. On 07/03/2025 LPA requested ER discharge paperwork for an incomplete SIR dated 06/24/2025. LPA noted that the ER discharge paper work was incomplete and contacted Administrator on 07/02/2025 by phone to reviewed CCL Regulations reporting requirements. Based on 18 of 105 SIRs in March 2025 through June 2025 being submitted past 7 days of the occurrence, and 7 of 105 SIRs review during that time not having attending physician's name, findings, and treatment, if any; and disposition of the case when residents returned from the Emergency Room, a citation is issued. Exit interview, report read, appeal rights and report provided.

The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Philippe Ryan Miles. On 12/17/2024, from 1:00pm to 3:45pm, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced initial complaint investigation visit to the facility. LPA Phillips met with Administrator Robin Murray and Community Relations Director Sarah Kau and explained the reason for the visit. During the visit, the LPA conducted in-person interviews at the facility pertaining to the complaint allegations, as well as requested and received facility documentation relevant to the investigation. The LPA determined further investigation was needed prior to issuing findings. On 12/23/2024, from approximately 1:04pm to 2:13pm, Investigator Miles and Investigator Heidy Bendana conducted interviews with Resident #1 (R1) and the resident representative for Resident #2 (R2); and on 04/13/2025, from approximately 11:54am to 2:04pm, with caregivers and med techs. The hospice residents (R2), Resident #3 (R3), and Resident #4 (R4) were not interviewed due to cognitive ability or being deceased. In addition, investigator Miles reviewed medical records from Assisted Home Health Hospice, Lompoc Valley Medical Center, Dignity Health Hospice, VNA Health Hospice, and facility file documents related to the investigation. On 5/30/2025 from approximately 10:10am to 10:50am, LPAs Haner-Tomasko and Jeffries interviewed additional staff and administrator. On the allegation: “Due to staff neglect, residents sustained injuries while under the care and supervision of the facility.” The investigation revealed that in October 2024, the facility increased the monthly rate for R2 due to the need of an “increase of the level of care and supervision,” however, R2 had an increase of witnessed and unwitnessed falls while sustaining multiple injuries. According to the Dignity Health Hospice medical records, it was noted R2 has had multiple falls. Caregivers stated R2 had multiple witnessed and unwitnessed falls, and behavioral episodes. Caregivers stated on one occasion, R2 went out a window, was found next door at Lompoc Skilled Nursing and Rehabilitation Center and therefore needed a higher level of care and supervision. (Continued on LIC 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 According to the Assisted Home Health Hospice medical records, on 12/04/2024, the Licensed Vocational Nurse (LVN) visited R3 and found multiple bruises to R3’s left shoulder. During assessment, R3 “had significant swelling and bruising to left shoulder that extended to left bicep and a bruise to [the] left wrist. Facility med tech states that there were no falls reported in the last 24 hours. Facility Administrator Robin Murray reports that she was going to investigate and interview all staff that helped with R3’s care within the last 24 hours to see if anyone forgot to write an incident report…”. On 12/05/2024, R3 was taken to Lompoc Valley Medical Center, and it was discovered during X-rays that R3 suffered an “impacted fracture on the humeral neck and fracture of the outer aspect of the humeral head with partial subluxation.” Caregivers interviewed stated R3 needed a higher level of care and supervision. According to VNA Health Hospice medical records, it was noted that R4 was a fall-risk with having frequent multiple falls in the facility. The caregivers stated R4, who needed a higher level of care and supervision, had witnessed and unwitnessed falls in the facility in which R4 sustained injuries. Based on the interviews conducted and supporting documents, there is sufficient evidence the facility did not provide a proper level of care and supervision to R2, R3 and R4. Therefore, the allegation is deemed Substantiated at this time. On the allegation: “Staff are not properly documenting incidents.” During the Department’s investigation it was revealed that R1 sustained 4 falls. R1 was admitted to the facility in July 2024 with falls occurring August, October, November and December 2024 , requiring medical attention; however only 1 incident report was submitted to Community Care Licensing (CCL). In addition, R4 had falls occurring February, April, and November 202 4 requiring medical attention, with no incident reports submitted. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegations: “Staff left residents soiled in bed for extended periods of time and Staff are not meeting residents’ needs.” It was alleged staff left residents soiled in bed for extended periods of time, and staff were not assisting residents during bedtime, as some residents were observed in the early morning hours to still be in their wheelchairs and regular clothes. (Continued on LIC9099-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 According to the interview conducted on 12/17/2024, the Administrator stated to LPA Phillips that the facility has had a hard time retaining and hiring employees to work there due to the location as the facility is located in an isolated town comparatively in the County. The Administrator stated that during the months of October 2024 and November 2024, a number of staff (between 5-10) had left employment at the facility due to a number of reasons including financial and geographic. The staff interviewed by the LPA stated that the facility is always hiring employees to keep staffing at an appropriate level, but it is extremely difficult due to the location. Staff also stated to the LPA that there have been "a lot" of falls in the facility in the second half of 2024. The LPA was told that it was not unusual. The LPA was also told that there is a high turnover and low retention rate at the facility, but they are always trying to keep, retain, and hire staff. Multiple staff interviewed by IB investigators indicated the facility did not have enough staffing to meet residents’ needs. Staff indicated some assisted living and memory care residents required one-on-one staff, and the facility pulled facility staff from the floor to provide additional supervision, leaving the rest of the facility short-staffed. Additional interviews conducted with staff revealed there was not enough staffing to meet residents needs, residents were left soiled for extended period of time, and other needs such as assistance with dressing and bedtime routines were not met. Additionally, staff interviews revealed the facility call buttons were not functioning for a period of at least t wo weeks; this was addressed on complaint # 29-AS-20250403091059. Interviews revealed the ‘loaner’ call system was providing the incorrect room numbers. Staff also stated residents were given whistles to summon assistance, however staff could not tell which rooms the whistles were coming from, and therefore did not respond to residents. While conducting interviews with the caregivers, they disclosed that Resident #5 (R5) eloped from the facility multiple times. R5 was discovered at a staff’s house in the neighborhood and was found near the main roads in the city of Lompoc. The local police department brought him back to the facility. Incident reports submitted by the facility revealed that R5 eloped on 07/05/2024, 08/02/2024, and 10/13/2024. R2 also eloped from the facility and was found next door at the Lompoc Skilled Nursing and Rehabilitation Center. Based on the investigation, there is sufficient evidence to support the facility did not meet resident’s needs, including residents being left soiled for an extended period of time. Based on the information obtained, the allegations are deemed Substantiated at this time. (Continued on LIC9099-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 A $500 immediate civil penalty is assessed today. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D). Exit interview conducted, appeal rights and a copy of this report issued.

On 03/28/2025, Administrator Robin Murray contacted LPA Jeffries via email and noted that the system had been down and there is a loaner system in place on 03/26/2025, while the main system is being repaired and 1-hour checks were be conducted by facility staff. Administrator Robin Murray stated that the loaner system had also been alerting inaccurately reporting the wrong room numbers. Administrator Robin Murray noted that the pull strings in each room were also not working and reporting correctly. At this time there is enough evidence to support the allegation of, “Staff does not ensure resident call buttons are in good repair” and is substantiated at this time. Exit interview, report read, report and appeal rights provided.

On 11/07/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced Case Management-Deficiencies visit. LPA arrived at the facility, met with Administrator Robin Murray, and announced the purpose of the visit. On 09/16/2024, Resident #1 (R1) sustained an unwitnessed fall while attempting to use the restroom, causing back and leg trauma. R1 stated to facility staff that they slipped and fell hurting their leg. R1 denied any pain medication and any medical treatment. The facility contacted the primary care physician for R1 who documented for the resident to continue their current plan of care. On 09/19/2024, staff documented that R1 was involved in an altercation with another resident. According to facility staff, R1 was struck by another resident in the face which caused R1 to begin bleeding. Facility staff documented that an incident report was completed, but the Licensing Agency has not received any unusual incident/injury report (UIR) regarding R1 while in care. On 11/07/2024/2024, LPA interviewed Staff about the lack of received Incident Reports to the licensing agency regarding either the incident on 09/16/2024 or 09/19/2024 occurring in the facility. The facility above has previously been cited for deficiencies regarding reporting requirements to the licensing agency on 07/11/2024. The facility will be cited for deficiencies regarding Reporting Requirements to the licensing agency. Exit interview conducted, a copy of this report was provided to the facility.

LPA confirmed through interview and record review that R1 was admitted to the facility above on 08/29/2024 and discharged by their responsible party on 09/19/2024. LPA requested and received Documented Narrative Charting by the facility for R1 while in care. On 09/19/2024, staff documented that R1 was involved in an altercation with another resident. According to facility staff, R1 was struck by another resident in the face which caused R1 to begin bleeding. Facility staff documented that an incident report was completed, but the Licensing Agency has not received any unusual incident/injury report (UIR) regarding R1 while in care. Through interview with LPA, it was stated that the responsible party of R1 visited the facility in September 2024 and observed R1 outside in the courtyard area of the facility wearing little clothing and shivering due to the cold. Staff documented in facility narrative charting that upon admission on 08/29/2024 R1 was an elopement/wandering risk. The Needs and Services Plan for R1 states the need for standby assistance from staff due to R1 being a falling risk and that R1 needs secure memory care due to a history of wandering and exit seeking behavior. Staff found R1 sleeping in another resident’s room on multiple occasions including 08/29/2024 and 08/31/2024. Staff also stated that on 09/10/2024, R1 needed to be redirected multiple times to leave another resident’s room after staff were notified by another resident that R1 was in their room. According to facility staff and narrative charting, on 09/16/2024, R1 had an unwitnessed fall while attempting to use the restroom alone. The Licensing Agency did not receive any unusual incident/injury report (UIR) for R1 while in care including the unwitnessed fall incident on 09/16/2024, nor the physical assault by another resident on 09/19/2024. Facility documentation states the need for R1 to have enhanced supervision due to being a falling risk as well as an elopement/wandering risk. However, multiple incidents involving R1 occurred in the facility which would not have happened with appropriate supervision by staff. Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated. Exit interview conducted. Copy of this report provided to 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 R1's responsible party stated that when they bathed R1 after discharge, there was dried feces all over the backside of R1. Documented Narrative Charting by the facility for R1 stated that on 09/18/2024, R1 was observed by staff to have soiled themselves in bed, which soaked through their mattress. R1’s resident assessment and R1’s needs and services plan both indicated that R1 required stand by assistance while bathing/showering 7 times per week. The resident assessment also stated that R1 bathes themselves with standby assistance daily in the afternoon. All staff interviewed by LPA indicated that resident assessments are followed, and all residents are bathed/showered regularly. All residents interviewed by LPA indicated they are bathed appropriately at the facility. LPA observed residents in the facility during complaint investigation visits on 10/11/2024 and 11/07/2024. During both visits, LPA did not observe any residents with dirty clothing, unwashed/greasy hair, and did not smell any noticeably unpleasant odors on any resident. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. On the allegation: Staff overmedicated resident. It is alleged that relatives of R1 felt they were overmedicated by the facility while in care due R1’s observed physical and mental state. LPA requested and received medical information for R1 while in care at the facility including the current medication record for R1 maintained by their primary care physician (PCP). LPA also received the medication orders and instructions provided by R1’s PCP with the listed medications prescribed dosage, symptom/reason, and quantity. LPA conducted record review of the individual narcotic record for R1 while in care at the facility. The individual narcotic record provides the name and directions for the medication, date and time provided, dosage, staff signatures, and amount remaining. LPA additionally reviewed the centrally stored medication and destruction record for R1 while in care at the facility as well as the medication release documentation for overnight visits and respite discharges. Record review of all medication information provided by both the facility and the PCP of R1 showed no evidence of any overmedication occurring by the facility to R1. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. 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 On the allegation: Staff did not safeguard resident’s belongings. It is alleged that when R1’s responsible party visited the facility in September 2024, R1’s shoes were missing and R1 was allegedly wearing other residents’ clothes. It is also alleged that R1’s responsible party brought a lot of clothing and belongings to have in the facility prior to admission. However, when R1 was discharged, the facility could not find any of R1's belongings and they were never returned. LPA requested and received the contents of R1’s facility file/record. However, there was no documented LIC 621 form Resident Personal Property and Valuables. LPA interviews with facility staff stated that R1 and/or their responsible party declined to provide a documented inventory upon entry into the facility. All staff interviewed by LPA stated that R1 had the items/belongings in their bedroom returned to them upon discharge from the facility on 09/19/2024, and that any item which could not be found was replaced promptly by the facility. LPA found no evidence through all interviews in the facility and record review of facility documentation that staff did not return R1’s belongings or replace R1's belongings upon discharge from the facility. Facility staff stated to LPA that a pair of R1's shoes were unable to be located, but stated that staff purchased a replacement pair of shoes for R1. LPA was provided evidence that R1 had their shoes replaced by the facility in an appropriate time frame. LPA additionally interviewed facility staff about R1 wearing other residents’ clothes while in the facility, but all staff interviewed stated that they did not witness R1 wearing other residents’ clothes. Facility narrative charting did document that R1 occasionally slept in other residents’ rooms and would have to be redirected to leave other residents rooms on multiple occasions, but there is no documentation of R1 wearing other residents clothing. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. Exit interview conducted. Copy of this report provided to the facility.

On 04/12/2024, LPA conducted an initial facility site visit for a complaint investigation into the allegations above. LPA interviewed residents, staff, and conducted record review of relevant documentation to the allegations. According to staff interviewed by LPA, on 03/28/2024, R1 had asked staff to get blankets because they were in cold water for a while. Staff interviewed by LPA stated they couldn’t tell how long R1 was in the shower. The staff stated to LPA that R1 was not unconscious or slumped over, but just was in cold water for a brief period. Staff interviewed by LPA stated that R1 should not have been in that shower location because it’s supposed to be closed as the drain clogs. The administrator of the facility stated R1 wasn’t supposed to be in that location, and that R1 has been told not to use that shower before, because it’s broken. The administrator additionally said R1 was taking a shower and dropped the washcloth. Staff stated to LPA that after the shower incident R1 was in their room with numerous blankets on, shivering. Staff interviewed by LPA stated that R1 had been in the shower, freezing cold, trying to warm up. Staff stated to LPA that R1 should never have ambulated from their room to the shower, with no walker present. LPA requested and received relevant facility documentation pertinent to the allegation. Through record review, the Physician’s Report for R1 dated 01/30/2024 states that R1 has the capacity for self-care including bathing and dressing/grooming. R1 has a secondary diagnosis of unspecified visual loss as well as a history of falls documented in the Physician’s Report. The mental condition of R1 is listed as confused/disoriented, but R1 has no documented wandering, aggressive, sundowning, or inappropriate behavior according to the Physician’s Report. Additionally, R1 has a documented physical health status of motor impairment/paralysis with an unsteady gate and refusal to use a walker. The Resident Appraisal of R1 dated 02/03/2024 states that R1 can care for themselves physically with the ability to understand and communicate their needs. The 02/03/2024 Resident Appraisal of R1 does state that R1 has had a decline in mental condition and cognitive changes. R1 is also documented to need required grab bars in the bathroom for safety but does not need help with bathing. However, the Resident Appraisal states that R1 does need help setting up a new environment when bathing. The 03/09/2024 Needs and Services Plan for R1 indicates that R1 has independent bathing during the morning (AM) everyday Monday-Friday. R1 is listed as able to shower on their own. Staff do need to set up the shower to ensure safety in a new environment. Staff will monitor R1’s hygiene for changes and staff should notify the home health agency representative if R1 requires assistance. R1 moved into the facility on 02/04/2024 due to anticipated decline related to a diagnosis of cancer and hospice needs. The Assisted Living Advantage Resident Assessment for R1 dated 01/25/2024 states that R1 bathes independently and showers on their own without reminders, stand-by assistance from staff, or total assistance from staff. 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 Documented Narrative Charting by the facility indicates that on 03/25/2024, R1 stated to staff that they fell out of their bed but denied any pain. The narrative charting states that R1 needs to be checked on more often. On 03/28/2024, R1 received a hospital bed and requires full assistance including the changing of briefs. Also, on 03/28/2024 narrative charting stated R1 was found on the ground in the bathroom, looked “out of it” and very pale. Home health agency services were requested. On 03/29/2024, R1 was found on the floor by the kitchen area of the facility and helped back to their bed by staff. Additionally, on 03/29/2024, R1 was found multiple times trying to walk around their room with an unsteady gait and lacking balance. A bedside commode had been ordered for R1 a week prior to the 03/28/2024 incident in the shower. According to interviews by LPA, the facility had installed the commode on top of the toilet without the basket. Eventually the basket was found, and staff were educated it should be bedside. R1 received a hospital bed and staff were informed to make sure the bedrails were up. On 03/29/2024, R1 fell out of the hospital bed, and staff were again informed the bedrail needs to be up on the bed. Staff were educated by home health agency representative on how to keep bedrail up, check on R1, and turn R1. Home health agency also provided a bed alarm for R1. On 04/04/2024, R1 had another fall from the bed with the bedrail not up as instructed and no alarm. The facility administrator stated that the bed alarm is not working anymore for R1, and they must have taken the battery out themselves. On 04/10/2024, Witness #1 (W1) visited the facility and observed R1 uncovered by their blanket, with a bruise on their hip. W2 stated to LPA that when asked about the bruise, R1 stated that they had fallen again. W1 stated to LPA that the bed alarm is supposed to be attached to R1’s bed, but it was under bed with the battery cover open and battery gone. Staff were unable to find batteries or cover piece for bed alarm. W1 stated to LPA that they were told by the administrator that R1’s home health agency needed to provide another alarm. W1 stated to LPA that they observed the bedrails on R1’s hospital bed not in the highest position and were crooked. W1 stated that R1 would not be able to move the bedrails on their own. Based on the information obtained, there is sufficient evidence that facility staff did not meet resident’s needs. Therefore, the allegation is deemed Substantiated at this time. On the allegation: Facility has insufficient staffing. It is alleged that the facility is understaffed which is detrimental to the care of residents. The allegation states that if the facility feels that they do not have enough staff to provide the care R1 needs, they need to alert outside agencies. It is alleged that there are not enough staff in the facility, and it was not a good idea for R1 to have moved in. 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 On 04/12/2024, LPA conducted an initial complaint investigation visit to the facility above. During this visit, LPA requested and received relevant facility documentation pertinent to the allegation. Through record review of the facility staff roster and the facility staff schedule, as well as LPA interviews with current staff, LPA was informed that the facility has been in the process of a staffing hire for multiple positions throughout 2024. The facility staffing hire was stated to LPA to be in response to vacant employment positions in the facility. On 08/29/2024, LPA conducted a subsequent complaint investigation visit and observed facility postings advertising hiring positions. Staff interviewed stated that many new positions have been hired in the facility in June and July of 2024. This was corroborated through record review of the current staff roster and schedule during the 08/29/2024 visit by LPA. Through staff interview by LPA, the facility is aware of the disadvantages of being potentially understaffed and have been actively trying to correct this through hiring multiple new employees. No resident interviewed by LPA in either the Assisted Living or Memory Care portion of the facility indicated that any of their Activity of Daily Living (ADL) needs are not being met by facility staff due to a lack in staffing. Based on the information obtained, there is sufficient evidence that the facility has insufficient staffing. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Facility did not contact responsible party about a change in condition. It is alleged that the facility did not inform the Power of Attorney (POA) for Resident #1 (R1) about a change in condition. The allegation states that R1 was independent when admitted into the facility, but is no longer independent. Through record review, LPA learned through the Physician’s Report for R1 dated 01/30/2024 that R1 has the capacity for self-care including bathing and dressing/grooming. On 03/28/2024, R1 experienced an incident regarding lethargy and disorientation while bathing/showering. R1 then agreed to a home health agency evaluation and a change in postural supports as well as medication. Through interview and record review by LPA, on 04/03/2024 the POA for R1 was contacted by Witness #2 (W2) regarding a change in condition for R1. The POA for R1 was unaware of the incident regarding R1 on 03/28/2024 or R1’s change in condition. Staff indicated R1 was lethargic due to home health agency hospice care. On 03/31/2024, W2 visited the facility and observed R1 in bed and lethargic. Through interview with staff, LPA was told that R1 was declining and needed an evaluation by a home health agency. W2 tried to confirm the POA of R1 would be aware of the change in condition. Through interview by LPA, it was stated the home health agency representative let the POA of R1 know about the change in condition. 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 W2 informed the facility that the POA needs to be informed of a change of condition by the facility as well. Based on LPA interviews with staff and records review, facility staff seemed unaware on the need for the facility to inform the responsible party of R1 about a change in condition. Based on the information obtained, there is sufficient evidence that the facility did not contact responsible party about a change in condition. Therefore, the allegation is deemed Substantiated at this time. On the allega

On 07/11/2024, Licensing Program Analyst (LPA) Brian Phillips conducted a case management-deficiencies visit to the facility above. During the visit, LPA Phillips met with Community Relations Director Sarah Kau as the Executive Director/Administrator of the facility was unavailable at the time, and explained the reason for the visit. During the complaint investigation of complaint # 29-AS-20240627081510, the following deficiencies were observed: There were no incident reports submitted for Resident #1 (R1’s) hospitalizations on 06/02/2024 and 06/11/2024 due to non-epileptic seizures caused by oral medications prescribed to R1 for cancer treatment in combination with radiation chemotherapy. There was no incident report submitted to Licensing on 06/12/2024 due to R1 being observed unresponsive and with no pulse by facility staff. There was no death report submitted for R1’s Death on 06/13/2024 while in the Critical Care Unit (CCU) of the hospital. R1’s representative was notified of R1’s hospitalizations and subsequent death. The facility acted appropriately in each instance to provide R1 appropriate medical attention. However, the licensee did not notify Licensing of the incidents or the death of R1. Exit interview, deficiencies cited, report given, appeal rights given.