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 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 was substantiated regarding missed medication administration due to failure in ordering and follow-up. The complaint about untimely call bell response was unsubstantiated after interviews with staff and residents and review of call response logs.

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

The complaint was substantiated. Allegations included failure to provide basic food services and overcharging a resident. The resident was charged for additional meals despite being in Assisted Living where meals should be included. The administrator refused to sign the report and plans to appeal the citations.

The investigation substantiated that the facility staff were not providing basic food services as required, specifically charging a resident for a third meal despite the resident living in the Assisted Living program where three meals should be included. The facility was also found to be overcharging the resident by charging for additional meals beyond the core service fee, contrary to regulations.

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 complaint was substantiated. The allegation was that lack of care and supervision resulted in resident death. The investigation included interviews, record reviews, and video footage analysis. The facility had a COVID outbreak impacting supervision. Staffing shortages and communication failures were noted. Immediate civil penalty of $500 was issued with additional penalties pending.

The investigation substantiated 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 stroke, severe injuries, and death. Contributing factors included staffing shortages, procedural failures such as lack of shift crossover, and delayed resident checks.

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 visit was complaint-related due to a self-reported incident where Memory Care residents missed morning medications. The facility promptly notified residents' responsible parties, hospices, and physicians, monitored residents for 48 hours with no adverse effects observed, and implemented corrective actions.

The facility failed to ensure that Memory Care residents received their prescribed morning medications because of the absence of qualified medication technicians. The facility took corrective actions including notifying responsible parties, monitoring residents, providing staff training, hiring additional staff, and implementing a staffing plan 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, triggered by an incident report of a medication error. The incident was substantiated as the medication error was confirmed. The staff member responsible was retrained and removed from medication duties.

The investigation confirmed that resident R1 was mistakenly given eye drops intended for another resident by staff member S1. The incident was reported timely, no adverse effects were noted, and S1 was removed from medication duties and retrained. A deficiency was cited for failure to comply with medical care regulations.

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 facility was generally found to be in compliance with regulations including physical plant safety, medication storage, and sanitation. 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 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 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 days.

The complaint investigation was triggered by allegations that staff were not following medical professional's orders, a resident sustained severe burns, and the facility did not ensure staff were trained to meet resident needs. The allegation of failure to follow medical orders was substantiated, while the other allegations were unsubstantiated.

The investigation found that the allegation of staff not following medical orders was substantiated due to failure to follow physician orders for sunscreen application, posing an immediate health risk. The allegations regarding the resident sustaining severe burns and staff training were unsubstantiated due to insufficient evidence. The facility has training programs in place but some staff expressed a need for additional training.

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 accidentally let a resident with dementia leave the memory care unit unassisted. The resident was missing for 50 minutes before being returned safely. The complaint was substantiated with a deficiency cited.

The investigation found that staff were not properly trained to prevent a resident from wandering out of the facility, resulting in a cited deficiency. The resident was returned safely and staff received immediate in-service training. A second incident involving a resident's change of condition was also reviewed with no further issues.

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.