Inspection Reports for
WellQuest of Elk Grove

The visit followed a substantiated complaint investigation (27-AS-20241007094603) that concluded on January 16, 2025, which found lack of care and supervision resulting in resident death. An immediate civil penalty of $500 was previously issued, and an additional civil penalty was assessed during this follow-up.

The Department determined that a civil penalty is warranted for a violation that resulted in the death of a resident due to inadequate care and supervision, specifically leaving the resident unattended outdoors in direct sunlight and heat, causing heat-related injuries and death. A civil penalty of $14,500 was issued during this visit.

The complaint was substantiated based on interviews, observations, and record review. Multiple staff and visitors reported issues with the patio chairs, including falls of two residents (R1 and R2) related to the chairs tipping or wobbling. The facility was cited under 22 CCR Section 87303(a).

The investigation found that the blue-and-black metal-framed chairs used in the memory care patio area between mid-May and late August 2025 were lightweight, flimsy, and posed a fall risk due to wobbling, tipping, and loose screws. Despite staff awareness and some maintenance efforts, the chairs remained available to residents for over three months, leading to substantiation of the complaint.

The complaint was substantiated regarding missed medication administration due to failure in ordering and follow-up. The complaint about untimely response to call bells was unsubstantiated after interviews and record review.

The investigation substantiated the allegation that a resident missed medication on 02/04/2025 due to failure in medication ordering and follow-up by staff. The allegation regarding untimely response to call bells was unsubstantiated based on staff and resident interviews and call log review.

The complaint investigation was substantiated. Allegations included failure to provide basic food services and overcharging a resident. Evidence showed the resident was charged for additional meals despite regulations requiring three meals daily under Assisted Living. The administrator refused to sign the report and indicated intent to appeal.

The investigation substantiated both allegations, finding that the facility charged a resident for additional meals despite the requirement to provide three meals daily under the Assisted Living program. The facility was charging some residents under the Independent Living rate, which includes only two meals, leading to overcharging and failure to provide basic food services as required by regulations.

The complaint was substantiated. The allegation was that lack of care and supervision resulted in resident death. The investigation included interviews, record reviews, video footage, and confirmed that R1 suffered heat stroke and died due to prolonged exposure to extreme heat and direct sunlight. Staffing shortages and procedural failures were contributing factors.

The investigation found that the facility failed to provide adequate care and supervision to resident R1, who was left unattended outside in direct sunlight and extreme heat, resulting in heat-related injuries and death. Staffing shortages, procedural failures such as lack of shift crossover, and delayed resident checks contributed to the incident. The allegation was substantiated.

The visit was complaint-related, investigating a self-reported incident where Memory Care residents missed morning medications due to staffing issues. The facility monitored residents for 48 hours with no adverse effects observed and took corrective actions.

The facility failed to ensure that Memory Care residents received their prescribed morning medications because of the absence of a qualified medication technician. The facility promptly notified responsible parties, monitored residents for adverse effects, and implemented corrective actions including staff training and hiring additional personnel to prevent recurrence.

The facility was generally found to be in compliance with regulations regarding cleanliness, safety, medication storage, and emergency preparedness. However, a deficiency was cited for housing 2 residents who became bedridden in units not fire cleared for bedridden residents, posing an immediate health and safety risk.

The visit was complaint-related, investigating an incident report about a medication error. The incident was substantiated as the medication error was confirmed, but no adverse effects occurred.

The investigation confirmed that resident R1 was mistakenly given eye drops prescribed for another resident by staff member S1. No adverse effects were noted, and the staff member responsible was removed from medication duties and retrained. A deficiency was cited for failure to comply with medication administration regulations.

The inspection found that seven of eight reviewed falls were unwitnessed, and the facility has implemented a fall prevention protocol including frequent resident checks, therapy programs, medication evaluations, and fall pendants. A deficiency was cited for late submission of a death report beyond the required seven-day timeframe, posing a potential health and safety risk.

The complaint investigation was substantiated regarding failure to follow medical professional's orders related to sunscreen application and medication administration for Resident 1. Other allegations, including resident sustaining severe burn and staff training deficiencies, were unsubstantiated due to lack of preponderance of evidence.

The investigation found that the facility did not consistently follow physician orders for Resident 1, particularly regarding sunscreen application, posing an immediate health and safety risk. Some allegations were substantiated, including failure to follow medical orders, while others, such as staff training adequacy and prolonged sun exposure, were unsubstantiated due to insufficient evidence.

The visit was complaint-related due to an incident where a staff member mistakenly allowed a resident with dementia to leave the memory care unit and the facility. The resident was missing for 50 minutes before being returned with assistance from law enforcement and fire department. The resident was assessed by EMTs and placed on alert charting.

The facility was found deficient for failing to ensure staff were properly trained to prevent a resident from wandering out of the facility. The deficiency was cited under CCR 87705(c)(3) related to care of persons with dementia. The facility implemented in-service training and plans to add signage to prevent recurrence.