Inspector’s narrative
What the inspector wrote
[CONTINUED FROM LIC 9099] R1 was not interviewed for this case because they had moved out of the facility by the date CCLD received the complaint, and then R1 passed away under hospice care, from their Alzheimer’s Disease, just two days later. Multiple family members unanimously reported that R1 could not be meaningfully interviewed during their final days.
LPA reviewed the hospice medication orders regarding R1’s ABH gel, which were signed and in Licensee’s possession, and the facility’s Medication Administration Records (MARs) on R1, showing when staff applied the ABH gel to R1’s skin, in practice. Together, these documents showed:
From 03/20/2026 through 03/31/2026, facility staff wrote in the MAR that the ABH gel should be applied to R1’s skin “every 8 hrs. routinely or every 4 hrs. as needed,” when in reality, R1’s hospice doctor had ordered the ABH gel to be given every 8 hours routinely, and additionally up to once every 4 hours as needed. In practice, staff applied the ABH gel to R1’s skin 2 times on 03/20/26, 1 time on 03/21/26, 2 times on 03/22/2026, 1 time on 03/25/2026, 1 time on 03/26/2026, 1 time on 01/29/2026, and 2 times on 03/31/2026. There were 26 missed routine doses of the ABH gel between 03/20/2026 and 03/31/2026.
Then from 04/01/2026 through R1’s move-out on 04/04/2026, facility staff wrote in the MAR that the ABH gel should be applied to R1’s skin “every 4 hours routinely topical for agitation,” consistent with a changed/updated hospice order executed around that time. However, in practice, staff applied the ABH gel to R1’s skin 1 time on 04/03/2026 and 2 times on 04/04/2026. There were thus 18 missed routine doses of the ABH gel between 04/01/2026 and R1’s physical move-out around midday on 04/04/2026.
Review of R1’s hospice agency’s visit records showed multiple of their nurses wrote that facility staff were not giving R1 their ABH cream as ordered, despite their giving corrective instruction. LPA’s interviews of multiple facility medication technicians showed they lacked clarity and consensus on the matter, and corroborated that the ABH gel was not given to R1 exactly as it was prescribed during the complaint period. Manager interview showed that during the complaint period, there was an unplanned staffing vacancy at the Resident Services Director (RSD) role, and there was no licensed nurse or pharmacist active on the staff roster. (This point is already being addressed in a separate Annual Inspection report.) The RSD is ordinarily the facility’s lead clinician who oversees the facility’s medication management program.
[CONTINUED ON LIC 9099-C, 2 of 2]
[CONTINUED FROM LIC 9099-C, 1 of 2]
Based on records and interviews, a preponderance of evidence exists to show that Licensee did not give a resident medication as prescribed. The allegation is therefore Substantiated, and one (1) deficiency was cited for it per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee.
An exit interview was conducted with Administrator Susan O'Shaugnessy, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
[CONTINUED FROM LIC 9099-A]
The Complainant said S1 and S2 then speedily pushed R1 forward in their wheelchair to their bathroom (located inside R1’s bedroom) without the footrests in place, causing R1’s feet to fold and drag behind them on the floor.
R1 was not interviewed for this case because they had moved out of the facility by the date CCLD received the complaint, and then R1 passed away under hospice care, from their Alzheimer’s Disease, just two days later. Multiple family members unanimously reported that R1 could not be meaningfully interviewed during their final days.
According to R1’s LIC602 Physician’s Report and Licensee’s preplacement appraisal documents, and corroborated by interviews of staff and outside sources: A few weeks before R1 moved into the memory care unit at Sungarden Terrace, R1 had a fall at their own home that resulted in a “displaced transverse fracture of right patella” (i.e., kneecap) and “other abnormalities of gait/mobility,” for which R1 underwent surgery. While living at the facility, R1’s dementia was pronounced, they were usually disorientated, were non-ambulatory status, were wheelchair-dependent and frail, wore incontinence products, and relied on staff to help them with mobility, transferring, and toileting, among other tasks. Hospice agency records further showed that R1 had been admitted to hospice care on 03/16/2026 for “Alzheimer’s disease” and “severe protein-calorie malnutrition,” that R1 “remained confused and agitated,” and that R1 was experiencing “delirium after anesthesia for [their] knee surgery.”
The Complainant provided the names of multiple outside visitors [Person #1 (P1), Person #2 (P2), Person #3 (P3), and Person #4 (P4)] who allegedly witnessed the 04/04/2026 transferring incident. LPA contacted each of these persons for interview. P1 said R1’s transfer was too “abrupt” and “fast,” and that R1’s feet dragged on the floor as S1/S2 wheeled R1 to their bedroom. P1 said S1 and S2 were similarly rough with R1 in the bathroom, as they transferred R1 on and off the toilet. P2 said S1 and S2 “seemed rough” in the way they “wrenched” R1 out of the living room recliner chair, but also acknowledged that R1 was non-alert, “deadweight,” and “hunched over” on this date. P2 recalled R1 expressing to the caregivers their desire to go use the bathroom, prior to the transfer. P2, who was very knowledgeable about R1’s care needs, explained that it was appropriate that staff purposely removed R1’s wheelchair footrests, since they presented more of a hazard than help to R1, given R1’s hallucinating and repeated attempts at pedaling themselves or standing up with the footrests still in the way. [CONTINUED ON LIC 9099-C, 2 of 3]
[CONTINUED FROM LIC 9099-C, 1 of 3] P3 said R1 was mumbling during the incident and that S1 and S2 were “a bit rough” during the transfer, but P3 also did not fully commit to saying that the transfer was objectionable. P4, meanwhile, did not respond to LPA’s multiple interview requests.
In their own separate interviews about the incident: S1 and S2 each told LPA that they worked together to transfer R1 from living room couch chair to wheelchair, in a coordinated fashion. They reported R1 on this date could not fully bear their own body weight. They both denied seeing R1 being resistant leading up to the transfer. They both said they each stood opposite each other on R1’s sides and lifted R1 from under their armpits and by grabbing the waistband of R1’s pants (rather than R1’s hands, elbows, or lower arms). They both denied being rough in lifting R1 up; they said the speed of the transfer was reasonable given that R1 could not help with their own legs. They both denied dropping R1 roughly into the seat of their wheelchair. They both explained that wheelchair footrests were intentionally not used for R1, due to their presence increasing the likelihood of injury to R1, considering R1’s known pattern of behavior. They both denied seeing R1’s feet drag on the floor as they wheeled R1 to and from their bedroom. LPA also separately interviewed 2 of 2 other staff who witnessed the transfer, Staff #3 (S3) and Staff #4 (S4), who both closely corroborated the points S1 and S2 had explained above. Inside the bathroom itself, S1 and S2 continued to provide two-person assistance to R1. They both denied transferring R1 roughly on and off the toilet. Another staff member was present for a portion of the time in the bathroom, and they denied seeing any rough transfers there, either.
LPA reviewed pertinent surveillance camera footage of the incident, which per CCLD requirements, depicted only common areas and hallways and featured video only, with no-audio component. There was a supporting post/column in the memory care living room which obstructed part of the camera’s view on R1. However, according to the footage: There was no clear visible evidence that R1 physically resisted staff leading up to the transfer. S1 and S2 positioned themselves on each side of R1. S1 and S2 bent their knees, paused, and worked together to lift R1 in coordinated fashion. R1 was deadweight. S1 and S2’s first exertion was not successful, and they immediately lowered R1 back to the seat of the chair. On the second exertion, they were able to lift R1 up and transfer R1 to their nearby wheelchair. During this second exertion, S3 even briefly reached in to assist, but by then the transfer was mostly complete. The available footage did not clearly indicate that either S1 or S2 had grabbed R1’s elbow or forearm area. Once in the wheelchair, R1 remained leaning/bent over forward with a hunched back, unable to sit upright, and appearing minimally-alert. [CONTINUED ON LIC 9099-C, 3 of 3]
[CONTINUED FROM LIC 9099-C, 2 of 3] R1’s legs looked thin and atrophied on camera. As S2 rolled R1 in their wheelchair to their room, they did so by walking the wheelchair backwards, with S1 walking behind them. There was no indication that R1’s feet meaningfully dragged on the floor during this transit from the living room to their room. A few minutes later, S1 rolled R1 in their wheelchair from their room back to the living room. This time, S1 pushed the wheelchair in a forward direction, but there was still no indication that R1’s feet meaningfully dragged on the floor.
Based on records and interviews, a preponderance of evidence does not exist to show that Licensee’s staff handled R1 in an rough manner, considering the overall context of R1’s physical and mental state during the incident. The allegation is therefore Unsubstantiated, and no deficiency was cited for it.
An exit interview was conducted with Administrator Susan O'Shaugnessy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
